GW1-2022-09235_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information-
(,�4use,
14:,V7ATER ZONES
Well Contractor FROM. TO DESCRIPTION
ftT116 it
5�0_ ft. ft
NC Well Contractor Certification Number
15:DUIER:QdSING,(fo"rmnlfi-rE sea )O '10II If
Morgan Well&Pump, Inc. FROM TO I DL4METZR I T. CTOTESS MATERIAL
Company Name +1 ft- b ft- 6 118/ f m sd,21 pvc
P Y I�6q/�L 16:II1IIdF�I2 CASING OR•TCIBING: •eo tlierm al•c1o'sed-moo
2.Well Construction Permit 4: FROM To DIAMETER TalcramS MATERIAL
List all applicable well const upon pernuts'r a UIC,Cow*State,Ym3mace,etc r fL ft �.
3.Well Use(check well use): fL ft is
Water Supply Well: 1'z SCREW,
1'rROM TO••: .•' DTAM=T Z SLOT SIZE •:THICKNESS MATERIAL.•,
Agricultural Di Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) MEesidential Water Supply(single) ft ft in.
I Industrial/Commercial E3Residenfial Water Supply(shared)
•.firi ation ::18:GROUT•:?..._ _ --<-.:.•.� : .:,%.�-',•��: '.:.::,_.,••_ :FROM I TO I MATERIAL - EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 20 f '
bentonite poured
Monitoring Recovery ft ft
Injection Well:
ft Aquifer Recharge K3 Groundwater Remediation ft
Aquifer Storage and Recovery S Basi !.-B:Si3ND/GRAVEDR6:CK tf ii"UckbIb
tY er FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test oStom mater Drainage ft
113 perimental Technology i�Di Subsidence Control ft ft
i Geothermal(Closed Loop) OTracet
:20.DRILLII�TGY OG'attitch addition'sl seets]f fiecess
1 Geothermal(Heating/Cooling Retum) -i Other(explain under#21 ) FROM TO DES PT ON(ado,hardass,sail/rock type,grain size,etc)
Qt O RL
4.Date Well(s)Completed: `^' WeIl ID# Q ft 20 ft ITEW
5a.Well Location: / ft. S
a ft ft vG Ire/5�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
�oSr Cva,Q er nv S1�S b , ft fi g
Physi Address, and Zip ft -
� yy�Y, ft Ala,.�,.,,=a.:�.•t'�' "�...
` -
County P —(/-�Parcel Identification No.(PIM i� i —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °-c- :^' ^1r�C?=-<•; ,_ {)r,;;
(ifwell field one]at/long is sufficient)
22.Certification: ✓:��i s�
6.Is(are)the well(s) Permanent or Oi Temporary Signature of Certified Well Contractor Date
�fY°���� 21 signing this form,1 heraly certify dial the wells)was(were)constructed in accordance
7.Is this a repair to an existing welL QYes or j No with ISA NU 01C.0100 or 15A NCAC 02C•:0200 Mell Constuction Standards and that a
IJihis is a repair,fill out known weAconst ucton iaiformadon and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remar/a•section or on the bark 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 NU MER'of wells construction details. You may also attach additional pages if necessary.
drilled:_' I
O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)Far molt 24a. For All Wells: Submit this farm within 30 days of completion of well
ple wells mar:all depths ifd fferent(example-3Q200'mGuill@I00� construction to the following.
10.Static water level below top of casing: ✓ d (ft) Division of Water Resources,Information Processing Unit,
IYwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to'sending the foil to the address in 24a
12,Well construction method: �0 r L above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rot construction to the following:
g rotary,cable,duectpush,etc.) � .
FOR WATER SUPPLX WELLS ONLX: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
6 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: ir4-nc>l as- Amount: Z completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department ofEnvftonmental Quality-Division of Water Resources Revised 2-22 2016
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