GW1-2022-10142_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information_
-14:,WATER ZONES:'. - r:' •:•'
FROM TO DESCRIPTION
Well Contractor Name n_J ft. jai � I
qS-0— [A ft ft.
NC Well Contractor Certification Number
I5:OrxERG4SMG,(&i&ulfl_rasaa webs)0121'II$1?,R
Morgan Well&Pump, Inc. FROM TO' DL4METFR THLQilE55 MATERIAL
+1 ft ft• 61!e! m' sdi21 pvo
Company Name ^= ;
CN,���A/G,,,������ O� 16��II11�R CA Sim OR•TLBIIVG.'-eotliet�sl•c1u'sed-lo6'
2.Well Construction Permit#: r, �/�I(� FROM To T)T TARTER TMcrQ,Fss ::f MnTExr�u
List all applicable well aonstr-uctionpernuts(i.e.UIC,Cowgv,State Parlance,etc} ft' ft. tr'
3.Well Use(check well use): ft m
Water Supply Well: I'T:SCREEN'.=:.: - .' •'•=°_ ::::;::. .,::;:`.;:::J-"r::.:.:::
FROM TO DIAMETER~ SLOT SIZE •.THICKNESS MATERIAL.
Agricultural QMunicipabTublic fti ft in•
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) in.
I Industrial/Commercial DResidential Water Supply(shared) -
Ini ation FROM TO MAT�RIAL ,• FAIPL4CEMENTMETH0D&AMOUNT
Non-Water Supply Weil: o zo ft ben'nRa pou2d
Monitoring Recovery ft ft
I
ection WeII: ftAquifer Recharge JDGroundwaterRemediation
SAND/GRAVFL•PAC�v a 'lirabl'eAquifer Storage and ReCDWTy Salinity Basier FROM TO MATERIALAquifer Test 13StormwaterDrainageExperimental Technology Subsidence Control ft. ft• DW01MM
Geethermal(ClosedLoop) �ITracer :2e..mRUIMgGSOG'(attach=additidnslsUetsifaecess-7q:='Geothermal(Heating/Cooling Return) -i Other(explain under#21 ) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain siz-,etc)
4.Date Well(s)Completed: Well ID# Q ft 70 ft �4^4 ok
Sa.Well Location: l t_' / / � V r ;
A kl w4-, wefsv ! ft ft
v� �
/owner ame Facility M#(ifapppli^ca le) ft.
CG 1 (� ft ft
PhysicAjdrcss,City,and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secon
ds or decimal degrees:
d,- y 1ptl1c� suf6cient)N 22.Certification:
W ..
6.Is(are)the well(s) Permanent or OTemporaty Signature of Certified Well Contractor Da`'te
!�� By si.pino this form,I hereky certffy that the we1Z(s)was(were)constructed in accordance
7.Is this a repair to an existing well• U'Yes or !No with 15.4 XCAC 02C.0100 or 15A NCAC 02C.02o0 Well Constuction Standards and that a
IJthis is a repair J1Z7 out known well construction information and explain the natm-e ofthe copy ofthis record has beenprovided to the well owvrer.
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: ' A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All'Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-3@200'and z@100) construction to the following.
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
IJwater level is above casino use"+" 1617 Mail Service Center;Raleigh,NC 27699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the farm to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r L` construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VLLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a Yield(gpm) Method of test: air pressure 24c.For Water Supply&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: 4ncm� Amount: i� 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 t, Revised 2 22 2016