GW1-2022-09275_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only. j I
1.Wen Contractor Information-
—GQCfeR c,QVse 14:.WATERZONES
Well Contractor Name FROM TO I DESCRIPTION .
5 VfL � i
NC Well Contractor Certification Number
I5:OUZER:G�ASING,(fo"r multi cased vteus b�2 LII�TF2 tf a'lirahIe)'
Morgan Well&Pump, Inc. FROM DL C TmCEaUM MATExIAi
Company Name +1 fL 1 6 1la/ I in' sd2l pvc
16`INNER CASING OR•TIISING: e6tbermaI clo's6A 6-6'
2.Well Construction Permit 4: FROM TO DIAMETER THIC.ENESS MATERIAL
List all applicable weII construction per nits'r e.UIC,Cowdv,State,Variance,etc-)• ft ft 'in.
ft M in..3.Well Use(check well use):
1. 17.SCRffiQ:i•.: :. .'-_':•: •.•:'
Water Supply Well: • -:. ...._ .•.•:...•..:• -:...-,....... :-.... .._
FROM TO DIAMETER~ SLOT SrZE THICKNESS MATERLAL.
Agricultural DMuaicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply)' DResidential Water Supply(single) tt ft m
I Industrial/Commercial E3Residential Water Supply(shared) _Irrigation 'PROM I TO MATERIAL'V EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: t kA. -- ft 20 ft bentonite. poured
'Monitoring Recovery r- ft ft
Injection Well: --
Aquifer Recharge ft ft
�J Groundwater Remediation_..,
NM.MfL/GLIR
Aquifer Storage and Recovery MSalinit)�'asI"erg":)�"";QiZOG -g Fgom TO CgMIfW ATERTAL EMPLACEMENTZYMMOD'
i Aquifer Test []Stormwater Drainage ft. ft.
+Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.tiRILLII�rGS OG'attacti additional slieetsneces' :: :' _ : '
FROM TO DESCRIPTION(color,hardness,soil/rock type,°rain si7^etc.)
t Geothermal(Heating/Cocag Retum) n-i Other(explain under#21 _ b,
4.Date Wells)Completed:" = Well ID# (� ft' ft- 164n LL
Sa.Well LOCati VA -\\ / R ft Ctq•
0�'O�S U ! n ft �� w •� ,h;
Facilittyy/OwrneerName Facili M#lgap li(cab�l/e�) ft
�I`\ � cal \ ft ft
Phys al Address,City,and 21p ft ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude m' deb ees/E* tes/seconds or decimal degrees:
g�e3aUlong i cient)N �^ 22.Certification: ^ 9
(�`U C, . f1 W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify fy that the weg(s)was(were)constructed in accordance
7.Is this a repair to an existing weII: 0Yes or t!No with ISANC4C 02C.0100 or 15A NCAC 02C.0100 F7eH Construction Standards and that a
IJihis is a repair,fR our known weD consbructon information and explain the nature ofthe SPY ofthis record has been provided m the well owner.
repair under##21 remark•section or on the backafthisform. 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 I GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
dulled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (fL) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths#dierent(example-3@200'ar d J@100) construction to the following.
10.Static water level below top of easing: ]v(/jC~J (ft) Division of Water Resources,Information Processing Unit,
IJwoter level is above casing,use 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r o"Y L` construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) V - Method of test: air pressure 24c.For Water SuDuly&Iniection Wells: In addition to sending the form to
- the address(es) 'above, also submit one'copy of this fors within 30 days of
13b.Disinfection type: C rtnc�l Qs Amount y completion of well construction to the county health department of the county
�� where constructed.
Form GWA North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
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