GW1-2022-08634_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only,
1.Well Contractor Information:
14:.WATER ZONES
Well Contracto)Name FROM TO DESCRIPTION
ft ft
G� r ft ft
NC Well Contractor Certification Number '
15:OUTM.cASINg for multi-rased wells)OR
Morgan Well &Pump, Inc. i mom TO. DIAMETER I THICKNESS MATERIAL
Company Name +1 ft. (� ft 61/8/ 1 in' I d2l pvc
�� / / i G OR•TUBI NG. -eotliermal c16'i&166 ''-�'
2.Well Construction Permit#: 14 / 7 %J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.LUC,Cowtty,State,Variance,etc.)- f• H- in.
3.Well Use(check well use): ft' in
Water Supply Well: 17.-SCREEN',:.'..: :;. .—.... .t- •` —
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
Agricultural QMunicipal/Public ft. ft in•
Geothermal(Heating/Cooling Supply) Mi Residential Water Supply(single) ft ft vt•
1 Industrial/Commercial Residential Water Supply(shared) _
18:GROUT-. _
1 I1Ti anon FROM TO; MATERIAL - EM7L-4rrmrriT m-mwnn&_4MOUNT
Non-Water Supply Well: a ft- 20 ft benton te poured
'Monitoring DRecovery ft. ft.
Injection Well:
��,{ ft ft
_I Aquifer Recharge 1�Groundwater Remediation r-. •. .
•.19:SAND/GRAVEL'PACK if a"licabie ...::. :=:.'':.:._ .:•. .. :-. -_.'... : >: _:.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater•Drainage ft ft
_I Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer :20.DRILLING.LOG'(attictisddition'il sl ied.ff iiecess"'':':' =s
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(cator,hardness,soil/rock a -n size,etc.)
7 ft ft -`t
4.Date Well(s)Completed: L yell ID# k
�j l�R' Q y
Sa.Well
{Location:
� "� ft 0>V f
Y1i1 l f ( O!1 ft J Fr
nrihty/Olvner Nameey� Facility M#(if applicable) ft. lJ ft. ` nn
J !/�/ ft ft ,
Physical Address,City,and Zip ft M
County Parcel Identification No.(PIN)
IJitir V`wr'll
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d m_-. r, .-
if well field,one lat/long is sufficientCertification:
(�r 7 1 z 22.
(� s L Vr 1 O8 ,N 9l o S-7 V � 4 W
6.Is(are)the well(s);gpermanent or OTemporary Ti:patuKofCert ed VAU Contractor Date
, 1r__ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No with 15A NCAC 01C-0100 or 15A NCAC,01C..0200 Well Construction Standards and that a
Ifthis is a repair-,fill out known well construction information a"``ndd'"VVVVesplain the nature of the copy of this 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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 ifdifferent(example-3(200'and 1(a3100D construction to the following:
10.Static water level below top of casing: 4 O (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 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
(L r Q Y LI
• e.auger,rotary,cable,directpuslr,etc.) J
construction to the following: '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Infection 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)��� Amount: 5 Q Z completion of well construction to the county health department of the county
where constructed. !
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources J Revised 2-22-2016