GW1-2022-10077_Well Construction - GW1_20221107

WELL CONSTRUCTI6N RECORD (G-V6 I) For Internal Use Only.
1.Well Contractor Information:
.,. 4:V.&=ZONES-
Well Contractor Name 'L:'k.,.r z 5'br t: FROM TO - DESCRIPTION
' ft ft .I
_ qrnlrS G — NOV 2Q22 ft ft
NC Well Contractor Certification Nnmbet
� 'I3:OD�ER:eA,SIN�.(fnc mm�lfi=eased wells)ORL•'i1�Elt(n:- 'Hcable)'�:�::'.'.::•••
Morgan Well &Pump, Inc. DMMZR I I THICKNESS MATERIAL
Company Name ✓:: is' +1 M 3 -ft
f 611B1 I in' sd,21 pvc
IrINNER CAENG OR TOBIN'G:rkifthdinQ cl6sed-166' 4 f:._
2.Well Construction Permitt': U`r L I FROM J TO I D100 FR I THICKNESS I MATERIAL
List aIlapplic-able weHconstruciionpemvts'(ie.MIG County,State Ymimrce,etc)• ft• ft in.
3.Well Use(check wen use): ft !L in.
Water Supply Well: 17_"SCREEN',::.: - .` _•.`_ ::'r::. ;,.:�:: -:=
1-,1 FROM TO DLIMETEF:� i SLOT SIZE THICKNESS MATERIAL
_t Agricultural 1=tMunicipal/Public . It fz
Geothermal(Heating/Cooling'Supply) esidential Water Supply jsingle) ft ft in. i
Sy
1 trmal/Commercial- _Residential Water Supply(shared) fiROUJ
laigation FROM To MA rFi= $MPLACEMENTMETHOD&_4MOTAVT
Non-Water Supply Well: o ft 20 fLbentonde• poured
'Monitoring Recovery & ft
Injection Well: ft ft
Aquifer Recharge �GioundwaterRemediation
:.79:SAND/GRe1VEL'PgCS ifa"linable ..-•--.;�::;=•. .'. . -••-.� �._
AgnifeStorageandRecovery DSalinityBamer FROM TO MA ERIAL M PLACEMENT METHOD
_`Aquiferr Test DSto�aterDrainage ft ft
Experimental Technology oSubsideace Control ft ft,
Geothermal(Closed Loop) 1Tmcer :2D.DRILLII�TGI OG'(attach-idditi6nal slifiets�faeces
Geothermal(Heating/Cooling Retain) J Other(explain under##21 Remallcs) FROM TO DESCRIPTION(color,hardnas,snil/roektype,gran sae,etc)
7 0 Q
4.Date Wells)Completed: o " 7�-21well ID# to ft ft iv N
5a.Well Location: `o ft
• ('e�h�,� Mn�n JGoc-�oS ft ft
Facility/Owner Name Facility ID;V(Happlicable) rZ
ft. ft
Physical Address,City,and Zip ft ft
i
County PatcelIdentificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one slat/long its sufficient) G� 22_C lion'
I
6.Is(are)the well(s)tb Permanent or OTemporary Si e.&C ell Contractor Date
By signing this form,I herabv cer&)5,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing welt ryes or Wo wi J 15ANCAC 020.0100 or I5 4 NCAC 02C..0200 WeU Construction Standards and that a
Ifthis is a repair f l out known we9 constriction information a,,texplain Use nature of the copy ofthii record has been provided to the well owner.
repair under B21 remarks section or on the back 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 details. You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells � -
drilled SUBMPTTAL INSTRUCTIONS
9.Total well depth below land surface: 7 On ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depMs ifdiierew(example-Jp_)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 casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 m.
( ) t 24b.For Injection WeILs: In addition to sending the form to the address in 24a
12. �a � above,also submit one copy of this form within 30 days of completion of we
Well construction ll construction to the following: I
(i.e.auger,rotary,cable,directpusb,etc.)
Division of Water Resources,Underkround Injection Control Program,
FOR WATER SUPPLY WELLS.ONLY: 1636 Mail Service Center,M Ieigh,NC 27699-1636
13a-Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
//�� /! 7 the address(es) 'above, also submit one I copy of this form within 30 days of
13b.Disinfection type: 'lam / 1,.b Amount: 0 L completion of well construction to the county health department of the county
where constrbted.
Form GW-1 North Carolina Department ofEnvuomnental Quality-Division of WaterResoumes I Revised2 22 2016
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