GW1-2022-10140_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For lateral Use Only:
1.Well Contractor Information:.
QC�P.T� C louse, •14:.%&TERZONES r
FROM TO DESCRIPTION,
Well Contractor Name 1
(�� p ft 1� tt
S 5 ft ft
NC Well Contractor CertificationNumbei I5:Op�M: G( r�lged wells)ORLII�FZ�
Morgan Well &Pump, Inc. FROM T DIAN=R R THic aT= MA ureT.
+i fieim
ft 6 118/ 0'�' sdr21 PVC
Company Name r y� •-..t. <,:
11 \ 16 II C 4fi]I�TG OR•Tt7BTNG: 'entaZ clp'sed lou
2.Well Construction.Permit#:
FROM TO DIAMETER THICKNESS .::•.MATERIAL
List aII applicable wen construction permits'(L e UIC,Canrty,Stat4 Variance,eta-f ft in.
3.Well Use(cherkwell use): ft ft m
Water Supply Well;-I 17_SCREEN',
� FROM TO DWt2EfER, SLOT SIZE ,:~THICKNESS�. . MATERIAL.,•
Agricultural ClMunicipaVFublic ft ft
!Geothermal(Heating/Cooling Supply)' &Residential Water Supply(single) ft ft. in.
I Industrial/Commercial E3Residentisl Water Supply(shared)
::18:GROUT•: .._. _.:; .. ='_--:'`.
In-i ation FROM TO MAa 7MAL EMPI.4CEMFNTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 Benton to poured
t Monitoring 1311ecr very ft ft
Injection Well: ft ft
-.a Well OGroundwaterRemediation ::19:5 /GRAVELPACgrfa"licalile '
Aquifer Storage and Recovery DSalinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test 0Stonnwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :2D.DRUSdTIGLOG'(aftach'sdditionaZsheetsnecess 7'i;^;;-s r:
FROM TO DFSCRIPT ON(color,hardness,soil/rocktype,o ain size,etc)
t Geothermal(Heating/Cooling Return) �Other(explain under#21 ) ft _ q
4.Date Well(s)Completed: (� WeIl ID# ft �, ft towti '�?
Sa.WellLocatio J ft J ft �/l '
or�b� ' ft ft r c-
Fac " i erName Facility ID#Ylicable) 10
Ck
ft ft IN ECEIVEtY
Oq0 e,�,,co '�'-� Cawft ft
Physical Address,City,and Zip ft.
ft
Cab,«.. :21i'RFMARTZR'�.:::i,:-%':i-....::.:`. -_ _'t:-=:.,•-':-_. —_
County Parcel Identification No.(PIN) DWOMOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
e ne is sufficient) / 22.Certification:
.N
, S
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
A 8v signing this form,I hereky cer4fy lhat the MEN was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or tNo win ISANCAC 02C.0100 or ISANCAC 02C.0200 Wen Consbvcdon Standards and that a
Ifthis is a repair fD out known weII consb•ucton information and eiplain the nature offhe copy offhii record has been provided to the well owner.
repair under 421 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,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: �V V (ft-) 24a. For All Wels: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdijferew(example-3 a 00'and 2@100) construction to the following.
10.Static water level beIow top of casing: �V (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 (in.) 24b.For Iniection Wells: In addition to(;sending the fans to the address in 24a
above, also submit one copy of this folml within 30 days of completion of well
12•Well construction method: r L[ construction to the following:
(.e.auger,rotary,cable,directpuslr,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) Method of test: alr pressure 24c.For Water Suuniv&Iniection 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: as— Amount: b/�/ completion of well construction to the county health department of the county
where constructed.
'i
Revised 2-22 2016
Form GW-1 North Carolina Depmtnent ofEnvimnmental Quality-Division of Water Resources 6