GW1-2022-08608_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1. ctor '
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" .- • .:. -
�� •14:.WATER ZONES
;', _ �:.. • .: ... ... ......:; :.... ..:- ':
Well Contmc FROM ft ft �TO DESCRIPTION
A r
ft ft
NC Well Contractor Certification Number
'15:OUTE•R_2ASING,(ioc tiiuIti=caged f've]Ls)OR LINER ifa--'IicahIe)'
Morgan Well&Pump, Inc. FROM TO' DIAMETER TEIIC124ESS MATERIAL
+1 ft ft 61l8! j m' sd21 pvc
Company Name ..
zti IIVNER G OR-TIIBING.' eotliermalclo'sed-loo :.
2.Well Construction Permit#: FROM TO DIAMETER THICHIVF.SS MA'rF:RTAT.
List all applicable well construction permits'(ze.UIC,Comity,Stale,Ymiance,etc)- ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: zZSCREEN'.;-:..;. _,. .` ;:?:: '.::-•'...: .:iC-:a." :;.:. .:<` '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
'Agricultural QMunicipal/Public ft ft in;
Geothermal(Heating/Cooling Supply) loResidential Water Supply(single) ft. ft in:
1 IndustriaUCommercial Residential Water Supply(shared) _ _ _ -
:Y8:GROUT:: .. .. :.:
1lrri ation FROM TO MATERIAL T EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft. 20 fL bentonite' poured
Monitoring QRecovery ft ft.
lGeothermal
jection Well:
Aquifer Recharge ft ft
q g �GroundwaterRemediation ,. .. . _ .r.. ;...SAND/GRA ._ ` : '.Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [2Stormwater Drainage- ft ft
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer :20.DRILLING.LOG"(attiiYidditia-iI slieed.>f(Heating/Cooling Return). Other(explain under#21 Remarks) FROM To DESCRIPTION.(cal r,hardness,soil/rock type,grain size,ete)
ft.
4.Date Well(s)Completed: . Well IN O It
ID-5ft
Sa e Location: ft S ft
it
AM In"t"Ej
Facility/O ner am Facility M#(if applicable) ft ft
ft. ^+
tf
Ad ess,��and Zip ft. ft MAY V
�Zq 5 �y :21:REMARKS :, ,'
County Parcel Identification No.(PIN) nt+` •� n ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
N W r/
6.Is(are)the well(s)*Permanent or [3Temporary Signa a Ce d Well Contractor Date
By sro this rm,I herebv certify that the well(s)was(were)constructed in ordance
7.Is this a repair to an existing well: QYes or *No with 15.4 KCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standw•ds and that a
Ifthis is a repair,fill out known well construction idformation and explain the nature of the copy of thii record has been provided to the well owner.
repair under#21 remarks section or on the back oflhis 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1Q100D construction to the following:
10.Static water level below top of casing: 3� (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 6 1 7
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: 0 r LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
• the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection ty e�J Amount: �Aoz, 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