GW1-2022-10208_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only.
1.Well Contractor Information_
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Clooze 14:.WAT7RZONES `. r :_'.�. ::'• .
FROM TO DESCRIPTION
Well Contractor Name ftI ft
✓ ®r fG it' I i,
NC Well Contrador Certification Numbet
` 'Li:O�R_QASIl�'G,(inc multi-rasedivells)'bRL'Q�T C� •lirihle)';,:=::'.:',::'•.-.:
Morgan Well &Pump, Inc. FROM xo' DIAIMTER I i T>�c>u�IFss MAT$
+1 ft C ft 6 11s/ t' sdr21 PVC
Company Name 3�61ti� - - ``
16`I1�IIQER C' G OB•TUBING. eothermal closed lri6'
2.wen Construction Permit##: FROM x0 DIAMETER f THICIINFSS M.sxExinI.
Lill all applicable we17constracdonpiawaIr'(La UIC,Cowgv,State,Variance,efcf ft ft
3.Wen Use(check well use): it. ft Supply Well. nL
Water Su 1 • 1'zSCREII�'',_:.:�::_,-• •''-�••._•'_.::� :-?::.• �::•, ;,.�'=::`;:-?• '�.;.•.•.:=•.' .•.
FROM TO DIAMETER SLOT SIZE THICk7ms 1vIATERIAL.
Agricultural lMunicipal Pablic ft ft �•
Geothermal(Heating/Cooling Supply)' MResideatial Water Supply(single) ft ft in
Industrial/Commercial E3Resideotial Water Supply(shared)
Irrigation FROM TO rvre rFmrer EMPI& t ~TROD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite pow
Monitoring Recovery R. ft
Injection Well: ft ft Ne
- 1
J Aquifer Recharge tGrundwaterRemediation
7g:SgND/GRAVEL'PA.. rf ti'livable
Aquifer Storage and Recovery nSalinityBanier FROM To MATERM Ym-e OD
I Aquifer Test 08tormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
iGeothermal(Closed Loop) Tracer :26.TrRIId1NGS:OG'(ittach=addition'slsheets neces's °:^'`•= `_' :' '=:FROM TO DES TION(color,hardnea,sail/roek type,graaih sve,ete)
I Geothermal(Fieating/Cooling Return) Other(explain under r 21 ) x ft � ft
4.Date Well(s)Completed: to 'L Well ID4 ft ft ^ f�
a ll Location: ft ft
5
I
s \ UL / ft ft
F •ty/ rName Facility M#Cif applicable) ft ft
ft. fL
ft ft.
Phys Address,City,and Zip _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cif Il i,ld o no l t' I� 22.Certification:6�
6.Is(are)the wells);Qpermanent or OTemporary Signatrrre of Certified Well Contractor Dam
By signing this form,I herebv certify that the weII(s)was(were)constructed in accordance
7.Is this a repair to an existing well M Yes or 14 No with ISA NCAC 02C.0100 or 15A NCAC 02C•:0200 Meff Conrttuctian Standards and that a '
If this is a repair,jiII out known well consow,n information and erphan the natw•e of the copy oflhis record has beets provided to the well owner.
repair under 421 remarks section or on the bade of this form 23.Site diagram or additional well details:
S.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 NUMBERbf wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total weII 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 ifdifferenf(eranple-3@2 00'and 2@100) construction to the following.
10.Static water level below top of casing: �� (ft) Division of Water Resources,Information Processing Unit,
.If wafer level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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: L[ construction to the following.,
(I.m auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL'ir_GVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) I Method of test air pressure 24c.For Watez SuuDly&Iniectl0n Wells: In addition to sending the form to
0�1 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ CtAol e r Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources f Revised 2 22 2016