GW1-2022-08614_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '"'4jPrlf forrrf: :•-
1.Well Contractor Info
r fion:
14:.WATER ZONES--,'. : r .
Well C ntrac r ame FROM TO DESCRIPTION
ft ft E
d ft ft k
NC Well Contractor Certification Number
15:OUTER CASING,(foi multi=rased(veils)Oft T7NFR if a"licahle' '.:c'
Morgan Well &Pump, Inc. FROM To nIAMETER T>�cre rEss MATR.RTdx.
�j +1 ft ft. 6 U8/ in. sd21 pvc
Company Name 1` � v" D 7- l
16:h�II�IER C' G OR TIIBIIVG. •euthe"r`mal•clb'sed-lod' .
2.Well Construction Per
mit#: FROM To DIAMETER THICKNESS I MATERTAT.
List all applicable well construction permits'r.e.V7C,County,.State,Variance,etc.),"�— ft ft m.
3.Well Use(check well use): ft ft. in.
Water Supply Well: . IZ:SCREEN'.:r.; `_:. . :_.:. :.;"rt:.•i; '•::-. ,-:.` .:ir.. -r:
FROM TO DIAMETER SLOT SIZE TMCKMS MATERIAL .
Agricultural rliMunicipaLTublic ft . ft in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft in.
I Industrial/Commercial E3Residential Water Supply(shared) GROUT.*?
E Irrl afion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 fL bentonite poured
Monitoring ORecovery ft. ft.
Injection Well: ft ft
_ Aquifer Recharge Groundwater Remediation r_ _ ,
�, 19:SAND/GRAVEL•PACK if a"hcabli :::_`;. ':...._ .:":'
'Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test Q Stormwater Drainage & ft
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) [ITracer :20.DRILLING.IAG'(attidi`addition'sl s'Sietsaf riecegs
i Geothermal(Heating/Cooling Return) ji Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/rack type,grain size,eta)
0 .ft. ft 1
4.Date Well(s)Completed:—Tv Well ID#f e2,.Oft L 0 ft-
ft G;l�
5a.Well Location: I
KQ i aW e r� ft
v i ft Q W LJ
Facility/Oer me ��11 1 Facility ID#(if applicable) ft ft l (01 (
Physical Address,City,and Zip �!� l ft. ft
�, ► 1 / L. �� �.� `21:"RFMARKC'- _ _ _ - - �' _
County / Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it��,./�,-�•;�F�^• r. n� '
('dwell field,one lat/long is sufficient) 22.C cation 'i:.�c�it lLrlJCIeSi tr 3 j
3 Ng l :���o w _� � �.
6.Is(are)the well(s)
,pPermanent or E3Temporary $ign a of Certified Well Contractor Date
By signing this form,I hereby certify that the welZ(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or I No with 15A NCAC 02C.0100 or 15A NCAC42C.0200 Mell Construction Standards and that a
Ifthis is a repair,fi11 out known well construction information and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back 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
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: - 1 /J SUBMITTAL INSTRUCTIONS
C
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ezample-3@20�0'and 2Q100� construction to the following.
10.Static water level below top of casing: �/ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: Y L� construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS 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&Iniection'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: C 1(� q/1 V Amount: / C.. 1y completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016