GW1-2022-08542_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD (GW-1) 'For Internal Use Only.
1.W Contractor I rmation: r
r _
r (� •14.. .&TER ZONES;.
FROM TO DESCRIPTION r
well Contractor are /'A ft lei ft I
3<72 A ft ft �
NC well Contractor Certification Number
15:OOTER -'IIcahIe'=, ":'.:,::
Morgan Well &Pump, Inc. : FROM TO' DLANIETER THICK`TEi 55 MATERIAL
+1 fL R' 61f61 sd21 pvc
Company Name / u M :..i i..:..
��b' "L O 16�II�I2 CASING OR•TIIBING: eotIierma7 cIiLUCaN ou
2.Well(nnStrreti0m Permit#: FROM TO DIANMTFu TMCIOUSS MATERIAL
List all applic llable we construction permiis'(l e.Wa County,Stag Variance,etc)• ft ft in
ft ft hL
3.Well Use(check well use):
17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE TATCKNESs 113ATERL4L.
Agricultural 014unicipal/Public tt ft in.
Geothermal(Heating/Cooliag Supply) residential Water Supply(single) ft. ft in.
IndustriaVUornmercial 3 Residential Water Supply(shared)
!Ili -at-ion FROM I TO MATERIAL EMFJ—A CEMYNT MEMOD&AMOUNT
Non-Water Supply Well: p ft 20 R bentonite• poured
Monitoring DRecovery ft ft
Injection Well: ft ft
_Aquifer Recharge �Grovndwater Remediation r._.:
•.19:SAND/GP&VEL•PA:CK if a`lirabre --:.•: ':::':
Aquifer Storage and Recovery 0SLinity Bawer FROM TO MATERIAL EiLOLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft
Experimental TechnologySubsidence Control ft ft
Geothermal(Closed Loop) 11Tracer 2D.DI2ILLIIIGLOG'(afiacliaddifional!sheets�fau' '. '^''=s 'i `,
FROM
I 9TO DESCRIPTION(color,hardness,soil/rock _ • size,etc.)
Geothermal(Heating/Cooliagg Return) �Other(explain under#21 Remarks) b R (40
d.CI
4.Date Well(s)Completed:O� Well M# fL Q ft r
Sa.Well Location: ft zoo
ft 61
OM Proo�Ftc� � ft ft ,
P
Facility/Owner N e Facility ID#(if applicable)
ft ft r
fL ft
g0 Fds debt a ,�l/C ft ft
Physical Address,City,and Zip
�wav� 701 ay
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field oae lai/long is sufficient) 22.C do
6.Is(are)thewell(s) rmanent or Temporary Si�atureofCertifie Contractor Date
By signing this form,I hw-ekv certify that the wells)was(were)constructed r accordance
7.Is this a repair to an existing well• Dyes or 0 with 15A NCAC 01C.0100 or 15A NCAC 02C:0200 F7eH Consn•uction Standards and that a
If this is a re pati;f:ll out known weA consbvctfon information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under 421 remand section or on the back of this form.
• 23.Site diagram or additional well details:
8.For Geo robe/DPT or Closed-Log Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
p p g
construction,only 1 GW-1 is needed. Indicate TOTAL NiJ1vIBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZOO (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esmnple-3@200'and 2@I00) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: L� construction to the following:
(Le.auge{rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELL&ONLY: 1636 Mail Service Center,,,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) �� Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type eA Amount: 7 completion of well construction to the county health department of the county
where constructed. 4
Form Gw-I North Carolina Department of Environmental Quality-Division of water Resources f Revised 2 22-2016
I