GW1-2022-10152_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:.
7 QC' w I Q Vse 14:.WATER ZONES-C. :,. :,•.. -
FROM - DESCRIPTION
Well Contractor Name� w fC f✓�o' (�
0-6, ft-
NC Well Contractor Certification Number
15:OUTEREA SINGdfor multi rased vlells bTTn�.R if likable)' '.:
Morgan Well&Pump, Inc. !10tMJ
TO DIAMETER THICIfiYFSS nxAzlxrAi
PVC
Company Name ft 6 1181 sd21 -
�_. 16 Ueum CASING OR•TOBING. "eutliermal dosed loo` : _'
2.Well Construction Permit 4: FROM TO DIAMETER THICI gEss MATERIAL
List all applicable weII construciion pernuts'rL e UIC,Cotartx State,Yaiance,etcf fL ft in.
3.Well Use(checkwell use): ft ft in.
Water Supply Well: 17 SCRELtN',_ :. .`� I '
FROM TO T SIZE THICIQiSSS MATERIARL4.L.
Agricultural0!MuaicipWPublic ft. ;r-
in•
Geothermal(Heating/Cooling Supply)' Di Residential Water Supply(single) ft hL
Industrial/Commercial E311esidential Water Supply(shta"ed)
k;Irrigation FROM TO MATERIAL - EMpi,&CEMENTMEMOD&AMOUNT
Non-Water Supply WeII: 0 M 20 ft
ben
tanite. ured
t Monitoring Recovery ft ft
Injection Well:
ft ft
AquiferRecharge oI GroundwaterRemediatiou _
7 !
Aquifer Storage and Recovery 6I Salinity Bawer ,FROM /ITTO PAS MATERIAL c 4 EMPLACEMENT 1 •OD
'Aquifer Test OStormwater Drainage ft. ft 1 pfx Una
1 Experimental Technology Subsidence Control ft ft
[1 Geothermal(Closed Loop) Tracer :20.DRUING.LOG'(ittich'sdditii,'"I heets�fneces 7":; =s :'€ •.` i:_`
FROM TO D CRIP ION(color,hardness,soiUrock type,grnin size,ete.)
I Geothermal(Fieating/CooIing Return)1 Other(explain under#21 arks) ft
4.Date Well(s)Completed: 0~` Well ID# e?ft ft
Sa Well Location: / & ?b ft
ft
Facility/Owner Name Facility M4(if applicable) D ft. ft Jf0Kf•
Physical Address,City,and Zip ft &
C.ah,�I.)� .�+ '21i'R'y:MdRR•R- __ _ _ _
County Parcel Identification No-(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tfg�ell fiel�e)�ry is sufficient) (�� � '� 22.Certification:
35. W. 01Q,�eber 11 Zort�
6.Is(are)the well(s) Permanent or ©ilTemporary Si eof Certified Well Contractor Date
By signing this farm,I herebv cerh,jy that the weII(s)was(were)constructed in accordance
7.Is this a repair to an existing well• ©Yes or l No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 WeH Construction Standards and that a
IJihis is a repair;fifl out Tao wn weD construction information and explain the nature ofMe copy ofthii 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 GeoprobeMPT 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �6 (ft) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For mulaple welh Ast all depths if different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: �bV (ft-) Division of Water Resources,Information Processing Unit,
If water 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
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 r LI construction to the following:
(1.e.augeS rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL �LLS ONLY: 1636 Mail Service Center,!Raleigh,NC 27699-1 63 6
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.. a r" Amount: completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2 72 2016