GW1-2022-09228_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only.
1.WeIl Contractor Information: r
14:.WATER ZONES;'.
Well Contractor Panic FROM TO DESCRIPTION
ft. ft
ft ft
NC Well Contractor Certification Number
15:OU�ER:CASIlVG,tflc multi=eased w a'-> .::
Morgan Well&Pump, Inc. - FROM TO' DlnbfETER ! THICIfi\FSS I MATERIAL
Company Name +1 Z 61/81 I!'' sd21 pvc
2.Well Construction Permit Z�.2�Q^ 1G:Il�*l�lt C6SIIQG O1t•TUBING: 'eotliermal•cln'se3lod` : -=••;' :•:;
#/: L FROM TO DIAMETZR THICKNESS MATERIAL
List all !sable well construction mw&s Le UIC,County, ft. ft m'
aPP• P State,Ymiance,eic.)�
3.Well Use(check well use): ft ft in-
Water
. 17.-SCREEN'.:,:.:Supply Well: FROM TO DIAMECEi SLOT srz> �TRicrrn�ss MATERIAL.
�Municipal/Public ft. ft- in.
othe (Heating/Cooling Supply) Residential Water Supply(single) ft tr,
vstn Commercial _i Residential Water Supply(shared) _;,: ••••- .-• .- .:.:.••_..:
S8 GRODT' -
:In'i ation FROM I TO MATERIAL' f EMPLACEMENT METHOD&AMOIINT
Non-Water Supply Well: o M 20" ft. bentonite. poured
MonitoringRecovery ft ft.
Injection Well: ft ft
Aquifer Recharge OJ Groundwater Remediation
•.19:S.&ND/GRAVEL'PACg ti a"linable "
'Aquifer Storage and Recovery �i ISaUnrtv Barrier FROM To MATERIAL, � r•.i I ..
—1 Aquifer Test Stoimwater Drainage ft. ft J
i Experimental Technology Subsidence Control ft ft , ' - -•`c=,ZJtI:'
Geothermal(Closed Loop) Tracer :20.DRILLII�TGLOG'(atiach=additiousl s7ieets�t iiecess 7': -
1 Geothermal(Heating/Cooling Return) �Other(explain under##21 Remarks) FRO -ft
nEs PTI ON(color,harnness,soiUrack tpp a grain s ze etc)
��]] �J O .f' Vey ;
4.Date Well(s)Completed: ��L�� Nell ID# Q. ft'
ft ft
Sa WeIi Location: �
�N`m
Facility/Owner Natat Facility ID#(if applicable) Z t ft- LA ey
��GI 11�• 2.��c1 5 ft. ft
Physical Address,City,and Zip ft. ft
County Panel IdentilicahZ n No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(3•well field,one lat/long is sufficient)
22.Certification:
7
6.Is(are)the well(s) !Permanent or Temporary SigaahiSO4Certified a CoKmetor Date
By signing This form,I hereby certify that the jwe1U(s)was(were)constructed in arrordance
7.Is this a repair to an existing well: QYes or No with 15ANCAC 02C.0700 or 15A NCAC 02C..0200 F7.9 Construction Standards and that a
If this is a repan•,fill out known well construction irifarmatit explain the nature ofthe copy ofthis record has been provided to the well owner.
repair underW21 remarks section or on the back of thisform.
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.
dulled_ SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: ,zoo (ft-) 24a. For All Wells: Submit this farm'within 30 days of completion of well
For multiple wells list all depths ifd ffi erent(example-3(200'm,d 2 a@100) constnrction to the following.
10.Static water level below top of rasing: O— (ft.) Division of Water Resources,Information Processing-Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.BoreheIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to'',sending the form to the address in 24a
12.Well construction method: r(3:::0�q above,also submit one copy of this fomm�within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
EWATERUPPLX LLSFtJNLY Division of Water Resources,UndergroundInjection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
Method of test air pressure 24c.For Water SuuDly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form witbin 30 days of
type: t Amount: completion of well construction to the county health department of the county
where constructed
fd
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22 2016
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