GW1-2022-09248_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information: - � ----------------
e � '
ZONES a'.
FROM TO DESCRIPTION .
Well C ntractor are � � f
NC Well Contractor Certification Number
i IS.0 TM—ASIIQG,(formulti=rasedweAs OILLII 7t(rf-'livable' :::',:•:: .`.:
Morgan Well &Pump, Inc. : FROM TO' DIAMETER THICISAIF C MATERIA
Company Name 0 ft LD� s t/S/ sdf21 pvc
` Ir�R CASING OR•TDBING: 'eotlier-mal closed-loo"!.'.:.,":..�• '..:.,":.'• . .
2.well Construction Permit,'-/: ,�'��\Q 1 �/(/n/ FROM TO DIAMETER THICIQIF.SS MATERIAL
List all applicable well construction permits'(ie UIG Cowo,State,P"aXa ce,etc), M. ft �.
ft ft
3.Well Use(check well use):
Water Supply WeIl: 17.'SCREEAr',=:.:'•:- .'�<-..:•�• _ .:;:•_,:.• �::. ..;,.:�,:'::.::-i7•'.�:;•.:,•.::.;
FROM TO DIAMETER SLOT SIZE THICIOWS MATERIAL..
Agricultural �MunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
lii3us Commercial Residential Water Supply(shared) -
In-i ation I FROM TO I MATERIAL EMPL4CEMENTMETHOD&_AMOUNT
Non-Water Supply Well: 0 ft 20 fL bentonite• poured
s Monitoring DRecovery ft ft.
laeothermal
jection Well: ft ft
Aquifer RechargeI Groundwater Remediation1�. 9:SANID/(YRAVEL'PACg rfiti��lirabl8 ..,:�. •'=.Aquifer Storage and Recovery SalinityBawer FROM TO • MATERIAL EHSPLACW=iv=OD
Aquifer Test Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft ,
Geothermal(Closed Loop) �ITracersh(Heating/CooEng Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hm do soilh-ock 'n size,etc)
n o ft
4.Date Well(s)Completed: `1 Well ID#/ ft. t 1D,rQ , /
Sa.WellLocation: /w /` fc ft p IA/n
ft ft 1 a 1
ty/owner Name Facility MO(f applicable) ft. ft
Physical Ad pdress,City,and Zi ft ft
County ParcelIcimb cation No.(PIN) 1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(dweell�field.,one lat/long is sufficient) 22.Certifiration-
N -� 11tiy7 W 4A0, 9_1� I✓"�
6.Is(are)the well(s) ermanent or []ITemporary S' of 66tified Well Contractor Date
7T By signing this form,1 hv—eby certify that the wen(s)was(were)consmucied in accordance
7.Is this a repair to an existing well;- aYes or I To with 1SANCAC 01C.0700 or IS.4NCAC 01C,0100 WeH Construction Standards and that a
If ibis is a repaB•,fig out known well consnucffon idformarion 6n1explain the nature of the copy ofrhis record has been provided to the well owner.
repair under421 remarkssecdon or on the bark ofthisform 23.Site diagram or additional well details:
S.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 / L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G(Q t) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths f rdiierew(erample-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: �(� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1 -36I7 Mail Service Center Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: 6 (in.) ` 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method- O L` above,also submit one copy of this form within 30 days of completion of well
(-e.auger,rota cable,direct push,etc.) construction to the following:
ry, '
L13b.
WATER SUPPLY WELLS,ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
Yield(gpm) V 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
Disinfection type: Amount: 11 • t/ 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 Revised 2-22 2016