GW1-2022-10141_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
i
1.Well Contractor Inform fation:
QCf��� �IQVS� -14:.WATXRZ0NES;'.
Well Contractor Name
F8 M TO I DESCRIPTION
�-1SS0 M ft
NC Well Contractor Certification Number
'15:OUP&gdSIIQG.(fnr m nlfi4ased wPDs)OR L•Tl3El.2 Crf'a'licahIe)' :�::`.:'.::'•.".;
Morgan Well&Pump, Inc. FROM T DIAAC FR MATHMUL
+1 ft ft 61/B/ m' sdr11 pvc
Company Name ,.•.. :..:
C u I,����O 1 I O FROM
Il�II�FSt CASING OR•TIIDiAz: 'entliermal'cl IC
2.Well Construction Permit#: HA �/{I L/b FROM TO DL9METER THICIfNESS MATERLSL
List all applicable well constructionpmnft'(z e.UIC,Cotmty,State,Piviance,eta,• ft• ft �'
3.Well Use(check weD use):
ft ft in.
Water Supply Well; . I SCREEN'.
'FROM TO I DWrLETER 1,SLOT SIZE -THICKNESS MATERIAL.
Agricultural UMunicipa]/Public ft ft in.
Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft _ ft in-
I Industrial/Commercial Residential Water Supply(shared) :18:GRODT:,• r
bIrrigation FROM TO I MATERIAL'- ZmpjP 4CRAMTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite Poured
Monitoring oRecovery ft ft
Injection Well:
Aquifer Recharge UGroundwater Remediation
:19:SAND/GRAVEL'PACg if a"liratile "
Aquifer Storage and Recovery �ISalinity Bawer FROM TO MATERIAL LA OD
Aquifer Test UStormwater Drainage f ft'
t Experimental Technology Subsidence Control fL an rx ft. "—"
UM
Geothermal(Closed Loop) K3TracBr :ZB.7DRULENG.LOG'(ittiLli=dditiouslsS9efs_tf`i0 ss ^' 'r'• .` 'i �c
I Geothermal(Heating/Cooling Return) Other(explain under#21 arks) FRO TCY I DESCRIP ION(color,hardness,soilfrocktype,grain sre,ete)
n ft ft. I TWIN f r
4.Date WeIl(s)Completed: WeII ID# 'P• it n tt,,
5a.Well.Location: L / ft ft � T�
Qme S '/v� / ft ft
Facility/Owner Name Facility ID4(ifapplicable) ft ft. M'`
�Z07 rt�lUs � ft ft
Physical Address,City,and Zip ft ft
C�7�f.t�tlS — `21FI2EMdRuc= _ —
county Parcel Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tiyj�fie, �g/lajl)qx��s cient) ( . �� ��y 22_Certification:
6.Is(are)the well(s) Permanent or [3Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the WER(s)was(were)constructed in accordance
7.Is Ibis a repair to an existing well: UYes or° I No with 15ANCAC 02C.0100 or 15r1 NCAC 02C.O100 FYeU Construction Standards and that a
Ifthis is a repair;fiII our known well consU urliors i»formaiion and explain the natw•e ofthe copy ofrhis record has been provided to the well owner.
repair under 421 remark section or on the bark 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 bf wells construction details. You may also attach additional pages if necessary.
drilled I SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: �/o (ft-) ?flu. For All Wells: Submit this form(within 30 days of completion of well
For multiple wells list all depths if different(example-3 nC200'and 2[a�100D construction to the following.
10.Static water level below top of casing: d (ft) Division of Water Resources,Information Processing Unit,
Ifwaler level is above casino 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
12.Well construction method O Y(r[ above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(r.e.auger,rotary,cable,duectpush,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) Method of test: air pressure 24c.For Water Supply&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:j f�U1 a'r Amount: d V completion of well coastnrction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources i Revised 2 22 2016