GW1-2022-08549_Well Construction - GW1_20220907

I r -ffi-vw�murrtcs
r Internal Use Only.
WELL CONSTRUCTION RECORD (GW-1). Fo
1.Well Contractor Information: r
Rre,A A WANERZONES
FROM TO DESt32LPTiON
Well Contractor Name `
3572 A M
ft ft
NC Well Contractor Certification Number '15;OUXE CgSlr7�.
Morgan Well &Pump, Inc. FROM I TO' D14MDTFR ' THICKNESS nATERIAL
+1 fi• gg ft 61/81 I in' sdr21 Pvc
Company Name ';'r'
rZ IC.'Z ER CAMNG OR•TuBiNG. g eotneimal clds8d-lod
FROM zo Drd
2.Well Construction Permit#: 37Z 5 ,�rF r�x Tr�CIarEss MATERIAL
fL ft in.
List all applicable well construction permits(Le.WC CaarN State,Variance,etc)'
ft ft in-
3.Well Use(check well use):
Supply SR SCREEAT'._-'. :.:_:.
Water Su .:r: ',::;,.: -`..-:.i;• R:;.•. .::'• .•.
pp Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural EjM9dcipaMblic ft. ft in.
'Geothermal.(Heating/Cooling Supply) P56sideatial Water Supply(single) ft ft in.
I Indus ommcrew i Residential Water Supply(shared) S: ODT�. •• _ ::r+- °..::- <�:' '` .' :': `
�I!, on FROM TO MATERIAL EMPL4CEMENTMETEOD&AMOIINT
Nater Supply Well: 0 ft 20Poured
oring Recovery & ft.
Injection Well: ft ft
- - —Aquifer Recharge nGroundwater Remediation ::: '•:;: r•::, ;. .••:
-19:SAM/GRAVEL'PACK If a'licabl'e "
Aquifer Storage and Recovery DSalinityBarrier FROM I TO MA METHOD
Aquifer Test QlStormwater Drainage fL fL
1 Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) r3Tracer :20.DRILLING.LOG'(atticli'addititinal isie6'tri ecess
'
1 Geothermal(Heating/Cooling Reet�tu--m) J Other(explain under#21 Rem FROM TO DESCRIPTION(color,hardness,soiliroek type, size,etc)arks) ft. ft C
re
4.Date Well(s)Completed: D'Z2 Well ID# ft 7 ft
S(a..Well Location: ,, ft
ilylC I GV Ll�illJ�X ft
ft.
p-.. .
Facility/Owner Name Facility ID#(if applicable) ft ft
qoo w;1 k,Ks ft ft _ r
Physical Address,City,and Zip ft ft M1
County ParcelIdentificationNo.(11K lJv
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cif well field,one lat/long is sufficient) 22.C ratio
6.Ls(are)the wells) Permanent or O1 Tempo;No
Signature of a ell Contractor Date
By signing this f 1 hereby certify than the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or with 15.4 NCAC 01C.0100 or 15ANCAC 01C.0100 WeN Construction Standards and that a
If this is a repair fR out brown well construction information and explain the natty-e of the copy of this record has been provided to the well rmmer.
repair underV21 remarla section or on the bath ofthisform 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 if necessary.
drilled: SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Art all depths 1f different(example-33@200'and 1QI00D construction to the following.
10.Static water level below top of casing: ✓0 A) Division of Water Resources,Information Processing Unit,
If water level is above casing,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: LI construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FQR WATER SUPPLY WEI LS.ONLY' 1636 Mail Service Centet,Raleigh,NC 2 7699-1 63 6
- i
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Inieeti011 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 (2�lDir 1 V✓ Amount: b& completion of well construction to the county health department of the county
where constructed
Revised 2-22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources