GW1-2022-09709_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
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1.Well Contractor Information:
C�K avt •14:.WATER ZONFS•:'. : :: : ,_• :..•.: .:
Well Contractor Name FROM TO DESCRIPTION
l ft 1 R1 ft
a7Z-A ft ft
NC Well Contractor Certification Number
'15:OUTER,G�ASIN�,(foc riiniti=rased svet)s)OR L•TNEI2(�_.licahle)'rJ:=::::.::'•.`.=
Morgan Well &Pump, Inc. FROM TO. DLUAWIZR THICffYFSS MATERTAS.
Company Name +1 ft- ft 61/81 m' sd21 pvc
�7 qq 161R CA�S]NG 012•ZTIBII�G.''eotliermalclo'sed-lod`: •.-• <.•:
2.Well Construction Permit#: O (- O � FROM TO DIAMETER TffiCENESS +~ MATERIAL
List all applicable well construction permits'(ie.ITIC,Couniv,State,Por once,etc} ft m'
3.Well Use(check well use): ft ft rn
E_'A2;dcn1ti1ral
pply Well: IVSCREEN'.= :,-. .`�: ..:•_.:::.:i'. :� ,:�::.`•.;:-.i�.:r,;•,:. :::'
FROM TO DTAME SLOT SIZE THICKNESS 141ATERIAL.
jM ai.Public ft ft �•
mal(Heating/Cooling Supply) esidential Water Supply(single) ft ft �•
Commercial 1 Residential Water SuPP1Y(shared) -_ =- - :•':
...
T� SIB GROUT"'
iui ation FROM TO MATERIAL EMPL-4CEMENTMETHOD&AMOIINT
Non-Water Supply Well: 0 ft 20 ft bentonite• poured
Monitoring oRecovely ft ft.
Injection Well:
ft ft
lGeothermal
Aquifer Recharge n Groundwater Remediatio
•.79:ShIiD/GRAVEL'P9,C'K Cif a"livable .._ •`• •.• -. -`--•: �..
Aquifer Storage and Recovery CISalinity Barrier FROM TO MATERIAL - EMPLACEMENT METHOD
Aquifer Test DStoimwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracet :26:DRILLING.TOG'(attacli additionalslieets�f aecess 7' :•:1i
(Ileating/Cooling Return) Other(explain under#21 Remarks) I FROM To DESCRIPTION(color,hard-ess,sail/racktype grain sac,eta)
ft 'I ft OUI V CUILA
Q
4.Date Well(s)Completed: ( ra Well ID# �s • ft `-f 0 rt f�bo f�Q—
Sa Well Location: 206 Y v
• k¢Ily� O�k1e�r � - ft ft .
Facility/0w erName Facility ID#(if applicable) ft ft
ft ft
�IZ�3 vl�is Ca�ecr�, rJL _
Pb//y/ss�iicalAddress,City,and Zip ft ft n
1.-A��VS `ZIc��.M:SRTCR= _ - `:i •:.:_•- .� :A-^:.-,=.::•:"_",.::.. -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(n well field,one lat/long is suin—cient) 22.C on'
3 6 79 -N -40. 5`7d-6 W
6.Is(are)the well(S) ermanent or [ 1Temporary Signature of Cuwwell Contractor Date
By signing this form,I hereby cej tfy that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well;- 0 Yes or with 15.4 NC.4C 02C.OI00 or 15,1 NCAC 02C..0200 FYell Constj=aon Standards and that a
If this is a repair•,ftII out known well construction information and explain the natut e of the copy ofthii record has been provided to the well owner.
repair under#11 remarks section or on the back ofthisform
23.Site diagram or additional well details:
8.For Geeprobe/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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V0 (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 5� (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
% t above,also submit one copy of this form within 30 days of completion of well
12.Well ]� LI construction method: construction to the following:
(Le.auge,rotary,cable,duectpusb,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS,,ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) [S Method of test air pressure 24c.For Water Suouly&Infection Wells: 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: Amount: 76 completion of well construction to the county health department-of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016