GW1-2022-08544_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: r
f 14:.WA.TER ZONES C,
FROM TO DESCRIPTION r
Well Contactor Name
3J�7 ISo f` 1" ft
R ft
NC Well Contractor Certification Number rf "lirahle
Morgan Well &Pump, Inc. FROM TO DIAMETER T731CKAESS MATERAAL
+1 R f fi 1/61 i m sd21 PVC
Company Name
16 71 R CA.S)TTG OR•TOBIAG."eotlier�s7 dBsed--loo" C'.:., '.- ;''`'•'
2.Well Construction Permit 4: JC_b FROM TO DIAMETER THICIINESS MATERIAL
List all applicable well construadonpermits'(£a V7C,County,State,Variance,etc.)- f M 3'
3.Well Use(check well use): S. f` 1 in.
[Water Supply Well: FROM TO DLkMETER SLOT SIZE THICrOMS MATERIALcultural L1 MunicipaUPublic ft ftthermal(Heating/Cooling Supply) esidential Water Supply(ogle) ft ft in.
usCommercial i Residential Water Supply(shared) •.,;_.... .�T•••
C]Inigation FROM TO MATERIAL Na1,4CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery R ft
Injection Well:
R R
Aquifer Recharge )Groundwater Remediation
•.19:SAND/MUVELPAC >f a'licalilb
Aquifer Storage and Recovery Dt Salinity Barrier FROM TO MATERIAL I' EL,&xLACErt=METHOD'•.
Aquifer Test C)Stormwater Drainage fL R
I Experimental Technology Subsidence Control R ft
Geothermal(Closed Loop) Tracer :2D.DRILLINGLOG'(attacli addifiifrisI'slieets�faeces's_7'''
1 Geothermal(Heating/Cooling Return) r-il Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock size,ete
O .R 46 ft. &LA
4.Date Well(s)Completed: T$-m Well ID# Q
ft —6 ft
52.Well Location: CP ft.
ft ft. �.. • ��5
Facility/Owner Name /�// Facility ID4(if applicable) ft 7
s LJr)/�rK 4 . / .Mljewl Lie- ,A/Cft R ft
Physical Address,City,and Zip In#�i'" ,,
Ate.pWR
•�0,, Wiwl -
County Parcel Identification No.OW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(d'well field,one laat/long is sufficient) 7tc 22.C do ..
` •5�(�g N _ 80,7327Z W �^
6.Is(are)the well(s). Permanent or C3Temporary S' of C ell Contractor Date
By signing this form,I herebv certify that the we11(s)was(were)constructed r accordance
7.Is this a repair to an existing well: ©Yes or To with ISA NCAC 02C.0100 or 15.4 NCAC 02C-.0200 FPeg Construction Standards and that a
If this is a repair fill out known well construction information and explain the nam-e ofthe copy ofthir record has been provided to rhe;well owner.
repair under 021 remarks section or on the bark of this form.
• 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages ifnecessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19TJcc (ft-) 24a. For All Wells: Submit this form within 30 day8 of completion of well
For multiple wells list all depths ifdilerent(example-3@200'mud 2@100) construction to the following:
10.Static water level below top of casing: "16 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 LI construction to the following-
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield Lapin) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
/+�
the address(es) 'above, also submit ohe copy of this fort within 30 days of
13b.Disinfection type:alb('iw Amount: 7pZ completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016