GW1-2022-10236_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
cjc,se .14:.WATERZONES C.
FROM TO DFSCRUTiON
Well Contractor Name � �
✓�o r fL fL
NC Well Contractor Certification Numbet t
� '15:OU�'ER•C�ASIl�TU',(fn"r tnniti-cased viPIlc)O_I"+�(rfa'lirahIe)',:`::'.:::'•.`.:
Morgan Well&Pump, Inc. FROM ITO' DL9NlSTER T)DCTL\FSS MATERUL
Company Name +1 ft. ft 6 1161 � '. sdt21 pvc :` +
�j 1 A� Icnom CASING OR•TDBIl�G. eotliermal clp'sed loti' _ ..
2.Well Construction Permit#:_ y Y1/ li vv l FROM TO DTdMFTFR TffC_MgBSS MATERIAL
List all applicable well construcSanpermits'(Le.UIC,Cam*,State,Pkr once,eta} ft. ft
3.Well Use(check well nse): ft. ft m
Water Supply Well:
FROM TO I DIAMETER~ !SLOTSM I TETCiCNFSS� MATERIAL.
PAgricultural rilMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) WResideniial Water Supply(single) ft ft. in.
ludustrial/Commercial DResifimtial Water Supply(shared) ;YS:GROUT::•. ::"' - -
Irrigation FROM TO - .`MATERIhI. -• EMPL4CEMLftTMETHOD1AMOUNT
Non-Water Supply Well: 0 ft 20 fL bentnnite poured
'Monitoring Recovery M ft. 1
fL
Injection Well:
Aquifer'Recharge QGroundwaterRemediation fL _ 2
:19:SAND/GRAVEL•PACK mf a"lieilile -.;:_4 "'• ..i-. _
' _
Aquifer Storage and Recovery Salinity Bawer FROM TO • MATERIAL 4 Ei OD
Aquifer Test OStormwater Drainage ft. ft DWQ1 a
t Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) 1ITracer :20.MPXMNGS:OG'(itticbadditiaidslieetsjdneces'
I Geothermal(Heating/Cooling Return) i Other(explain under#21 ) FROM TO DESCRIPTION((calor,hardness,sail/rocktype,gra size,etc)
0.ft LP ft V l
4.Date Well(s)Completed: 0' Well ID# ft ft
Well Location- / ft fL �qa-w c, —
5
Fac•' /OwnerNVAA ame
(ff Facility ID# applicable) ft t f
�
st
Pbys�3j Address,City,and Zip ^` V ft ft
1Lo�� - _
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifWell fiea oaelat/lo js,sTcient) �I 22.Ceriifiration: /� �J �]
(i .N ' �q W V lam —
6.Is(are)the well(s) Permanent or ©ITemporary Signature of Certified Well Contractor Date
By signing this farm,I hereby ce77ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M'Yes or°4j No with 15A NCAC 02C.0100 or 15A NCAC 02C,0100 WeH Construction Standards and that a
Ifdis is a repair,fill out lmown weII consbuction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 4J21 remarla section or on the back of this form
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geo 4 o only
1 G or s needed.
I Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER�ofwells
drilled:_ ' 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: w U (ft-) 24a. For All Wells: Submit this foim within 30 dayt of completion of well
For multiple wells&i all depths frdifferent(eratnple-3(Qa 200'mid 2 00) construction to the following
10.Static water level below top of casing: L (ft) Division of Water Resources,Information Processing Unit
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniecdon Wells: In addition to!sending the form to the address in 24a
I above, also submit one copy of this foffi within 30 days of completion of well
12.Well construction method: A Y L` construction to the following:
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
1C I
13a.Yield(gpm) ` J Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
r� 0 the address(es) 'above, also submit one Dopy of this form within 30 days of
13b.Disinfection type: r1 C 4,,y1 G r Amount: �, completion of well construction to the counfy health department of the county
where constructed
Form OW-1 Nortb Carolina Department ofBnvironmentsl Quality-Division of Water Resources Revised 2 22 2016
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