GW1-2022-10722_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GW-X) For Internal Use Only
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l._Va"ontractor Information: ' r
l Qi4 14.WATIIt ZONES "=
FROM TO. DESCRIPTION c
Well Contras r Name G ft j(��j� ft ?
NC Well Contractor Certification Number 15:OU�EReASII1G,(fai multi=cosclams
'licahle M'�T
=;:•:::•
EPJAL
Morgan Well &Pump, Inc. _ FROM TO DlSMFTER Tmr1�1>ss
+1 ft ft 61/SI In- sd21 pvc
Company Name . 16 G 012•TIIBING. e6tlierma7 closbd lou' r
2.Well Construction Permit#: FROM ft TO ft in. KN DIAMETER THICESS .�:+.MATERIAL
List all applicable well construction permfts'r a VIC,COtatty,State,V""ance,etc-)•
M ft in.
3.Well Use(check well use): S w':• ::_-: r.- :::
17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCICNCSS MATERIAL.
Agricultural ni MunicipallPublic ft ft in.
Geothermal(I3eating/Cooling Supply) JoResidential Water Supply(single) ft ft
Tndustn Commercial 'Residential Water Supply(shared) 8 ROLt T
FROM TO MATERIAL EMPL4CEMENTME OD
TH &AMOIINT
•,Ini lion
Non-Water Supply Well: D ft zD f Benton te• poured
MonitoringRecovery ft ft
Injection Well: �—,} M ft.
Aquifer Recharge ni Groundwater Remediation :;: '• = ::':'
�19:S2,ND/GRAVEL'PACK if a"licaBle EMPLACEMENT il�THOD+
•Aquifer Storage and Recovery DSalinity Barrier FROM TO MATE'RL4L 7
Aquifer Test 01 Stormwater Drainage ft ft J
_Experimental Technology DSubsidence Control ft fL
Geothermal(Closed Loop) OTracer :20.DRILLi1TG.LOG(aCacti addiiiuna7
FROM TO DESCRIPTION(color,hardness,seil/rock ty e,U=size,etc)
Geothermal(Iieating/Cooliag Return)�,.�Other(explain under#21 Remarks) O � ft
4.Date Well(s)Completed: \1 00 1 12-W-11 ID# ` fL ft
Well Location:
5 ft 50 ft
ft s���ft
Faw7i /Owner Name Facility ID#(if applicable) ft LJt.�-�ft t-�
1 ft ft sm..
Physical Address,City,and t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in decrees/minutes/seconds or decimal degrees:
(rf well field,one lat4ong is sufficient) 22. ration:
6001i .Nan Z UP W
Sign ed Well Contractor Date
6.Is(are)the well(s)#Permanent or QiTemporary
t form,I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or ENO 15A N C 02C.0100 or ISA NC4C 02C.0200 P7ell Construction Standmdr and that a
Ifthis is a repair,fill out(mown well consi action information and explain the natm•e ofthe
y of this record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform. 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 N1J1vIBER7of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L CO —(ft-) 24.,,L For All Wells: Submit this form within 30 day.s of completion of well
For multiple wells list all depths if different(example-3@200'mid 2@100) construction to the following.
10.Static water level below top of casing:A< (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f- Ir construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) J '
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELL&ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suppy,&Injection 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. 0 V� Amount: ��L completion of well construction to the county health department of the county
where constructed
Revised 2 22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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