GW1-2022-10149_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-I) Pot Internal Use Only.
1.Well Contractor Infoorrmation: \ r
A•Y `y� U 1� •14:.WATIIL ZONES•:'. �:•: .� :''•',.
Well Contractor ame FROM TO DESCRIPTION
ft ft
lY•� 'j�l/. ft ft
NC Well Contractor Certification Number
15.O=-R.•GASING,(&i multi-rased webs OR L'IIITFlt
Morgan Well &Pump, Inc. FROM TO' DIAIvIET7+R THICKNESS MATERL4i.
Company Name +1 fL ft- 1 6118/ 1 in. sd,21 pvc
�,O I INNER CMII�TG OR-TUBING eotfiermal cldsed loo' t ..."-
2.Well Construction Permit#}: c20? FROM TO DIAMETER THIciOMS MATERIAL
List all applicable well construction permits(ie.WC,Coua ,_&aL4 Ymiance,etc.)• T fLfL
'
3.Well Use(check well use): ft ft tin
Water Supply Well: . 17.•SCREEN :..-. `_.-. .`• _`_ r it:..i.:�;: _;,.:�,-:.;:-iL.: :;.:. .:::` .'
FROM TO I DIAMETER I SLOT SIZE I THICKNWS MATERIAL.
Agricultural _ 13Municipal/Public ft ft in
Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) I ft ft in
)^ndustnaUCommercial J Residential Water Supply(shared) 1 "•.: ...: .•, :..,.: ... :. •.. -... _ .:, =,:....:
laiRation FROM I TO I MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o fL 20 ft bentonRe poured
Monitoring ORecovery fL
ft
Injection Well: WED
ft
J Aquifer Recharge �f Groundwater Remediation fL
.19:SAND/GRAVEL'PACg tia"livable •'•
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLAC&)MNT METHOD
J Aquifer Test OStormwater Drainage fL ft inkwu4an Pr?c UMExperimental Technology )Subsidence Control ft ft, W
Geothermal(Closed Loop) J3Tracer :20.�IULLII�TGS OG'(attacli8dditionsl sheeis�t ue "7'; -
Geothermal(Heating/Cooling Return) J Other(explain under#2l Remarks) FROM TO DESCRIPTION(color,hnrdn soillrock type,grain sae etc)
4.Date Well(s)Completed Well M## ft ft
Sa.Well Location: S R f, Vp'1/J n
Facility/Owner Name Facility ID#(if applicable) M fL
O Grrz e-++ ft ft
Physical Addr=,Citz an`d^Zip ft ft
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tfwell field,one lat/long is sufficient) 22.Certifiration•
.3r-3 0 -N W
6.Is(are)the well(s) Perraaent or O!Temporary Sigriat6eof Certified Vell Contractor Date
` By signing this form,1 hereby certtfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well K]Yes or bd
Ilo w1di 15A NCAC 02C_0100 or 15.4 NCAC 02C.0200 WeII Construction Standards and AW a
Ifthis is a repair fifl out known well cowh—son information erplain the narw-e of the copy ofthLi record has been provided to the y ell owner.
repair under#l21 remarks section or on the back ofhUsform 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: tl SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `y 1 (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@2 00'an72@100) construction to the following:
10.Static water level below top of casing: y (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor-chore diameter: 6 (in.) C 24b.For Infection'Wells: In addition to sending the form to the address in 24a
L� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method
construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
LFORATER SUP LY WELLS.ONLY• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
ld(gpm) Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
/� �nflthe address(es) 'above, also submit one'copy of this form within 30 days of
infection type:C, / / Amount: L 1 07, completion of well construction to the county health department of the county
where constructed.
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016