GW1-2022-09251_Well Construction - GW1_20221003

WELL CONSTRUCTIbN RECORD (GW-11 7Forernal Use Only: i
1.Well Contractor ormation:
J/�l ` [q� •14:. ATERZONF.S•:'.C� TO �DESC RIPT ....•.;.....•.. ...._:.:; :.... _ ...1v�� o "" " FROM ION c
Well Contractor Name 5 M of* ft363Z-A ft 492- t" _
NC Well Contractor Certification Number 15;OUXER:G�ASIN�,(fo`r multi cased R I I OR LI13ER Cif IIcahle)'-1;'.
Morgan Well &Pump, Inc. FROM TO' DIAMETER t ! TmcrstEss MATERTdr.
+1 ft ft 61181 sd21 Pvc
Company Name 1rn' I&R gCASINGog.TUBING' eoth6rmalclosedlou" ''
FROM TO DIAMETER: TEICIQ�SS ... MATERIAL
2.Well Construction Permit : D D ft. fL
List all applicable well consbuctionpermits-rL&UIC,CounlR State,Variance,e!c)
ft fG m.
3.Well Use(check well use): :•` ;•::••:. ;,.: `:-.i;. .?.:. .::` '
Water Supply Well: FROM TO DWNETER SLOT SIZE TAICIO ESS MATERIAL.
Agncultural Mi Muaicipal/Public fL m'
Geothermal(Heatiag/Cooling Supply) dential Wafer Supply jsingle) R ft in
I ZndustnaUCommercial J Residential Water Supply(shared) �GR.0.
FROM TO t re t Fnrar_ EMPL4CEMENTMETHOD&AMOIINT
i I>Ti ation
Non-Water Supply Well: 0 ft. 20 ftpoured
bentonite•
'.Monitoring DRecovery ft ft
I
ell:
echarge7GroundwaterRemediation %-9:SAND/GRAVEL'PACKEISPLACFMENT 1�THOD
torage and Recovery DSalinityBairier FROM TO MATERIALest DStormwater Drainageental Technology Subsidence Controlal(Closed Loop) OTracer :20.17D) I�rG-Log(atizcti`additi6'nsl slieetsjd iiecess 7'^'FROM TO DESCRIPTION(color,har8aess,soil/roek e,grainsaE,etr)al(Heating/Cooling Return) rjj Other(explain under#21 Remarks) O
4.Date Wells)Completed: q-q-2Z Well M## 4(• It bs ft C
ft. fL
5a.Well Location: lV
n Y f ft ft 1
k eve �yl l ft ft -
Facility/0 Name Facility ID#(if applicable) r
fL fL
JZ
a 1 S �► a r
Physical Address,CV,and Zip ft ft _- Q C
��
1�
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rf well field,one laUlong is sufficient) �t� c� Q� jCtalin:35'. 3$Z6 'N 401W ed Well Contractor Date
6.Is(are)the well(s) ermanent or Temporary
By signing this form,I hereby certify that the wen(s)was(were)construcrr�in accordance
7.Is this a repair to an existing well: M'Yes or 04 with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Wa Construction Standen ds and that a
If this is a rep®:fill out Imo wn we➢construction iriformation and explan the na w-e of the copy ofrhis record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUNMER'of wells
drilled: `� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�S dJ (ft-) 24a. For All Wells: Submit this farm within 30 days of completion of wen
For mulhple'we&list all depths ifdifferent(example-3(200'and 2@100) construction to the following.
10.Static water level below top of casing: Z15 A) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" tt 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) C 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: �L� construction to the following:
(Le.auger,rotary,cable,direct push,etc.) J
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: air pressure 24c.For Water Supply&IniectionVelis: 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 Mowoug Amount: ���- completion of well construction to the county health department of the counts'
where constructed-
Form
GW-1 North Carolina Department of Environmental Quality-Division of WaterResources •I Revised 2 22 2016