GW1-2022-10723_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information: r
•14:.WATERZONES:'. i :('•':..-
tl FROM I TO DESCRIPTION
Well
(Co�ntracttDr ame ft ft
—A ft ft
NC Well Contractor Certification Numbet '15:OUTZR-CASING,(fnc multi=rasea,*Zs)bRIDIEI2 rfa'IIcible'
Morgan Well &Pump, Inc. FROM TO' nIAMETI TEICKINWS MATERL+3
+1 ft ft 61/8/ m' sdr21 pvc
Company Name ,-... ,_;•,..,.
16 Il�I I1 I2 CASING OR•TOBI A M:'-eotfiermal cl ICE 1od
2.Well Construction Permit#: L n FROM TO DIAMETER THICKNESS MATERTdT•
ft, ft in.
List all applicable well construction pmnitsAe 67C,Courgv,State,Variance,etcr
ft ft in.
3.Well Use(check well use):
. 17_"SCREEN',=�. :<.�`:r. .`-�,.-.•:-'_.:._:•:::�:.• �:::-',::;..:'�.:-:.,•:=.
Water Supply Well: FROM To DIAMETER SLOT sr2E MCKMS MATERTAL.
Agricultural MunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industn Commercial 1 Residential Water Supply(shared)
•Irri tion FROM TO MATERIAL EMPL.4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: _ o ft- 20 ft bentonite poured
Monitoring Recovery ft ft.
Injection Well: ft ft.
Aquifer Recharge I Groundwater Remediation
,.19:SAND/GROEL'PAcic rf
Aquifer Storage and Recovery Salinity Barrier FROM TO • MATERU L EL,2L&CEMENT METHOD
Aquifer Test O Stormwater Drainage F: ft ft
i Experimental Technology Subsidence Control ft ft
iGeothermal(Closed Loop) �ITracer :20.DRILLII�TGZOG'(attaililiadditionalsheetsjdnecess"
FROM TO DESCRIPTION(color,hardness,soillrock typ size,etc)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) ft O ft
7
4.Date Wells)Completed: - 3 Zell ID# ft ft r0
5n.Well Location: ft ft
ft ft
_ Ll l�otn/se ft
Facility/Own Name Facility ID (ifb applicable) ft ft
ft ft L F d
Phy�sT�eaal Ad
dress
,
City,and Z
Fed ASV[JV ZL'•u FrvreuuG' -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d •�*
(ifwell field,one lat/long is sufncient) `")( 22.Certifi
6.Is(are)the well(s) Permanent or QlTemporaiy
Signature of Certified Well Contractor Date
By scorning this form,1 he? cepfy Thai the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well ©Yes or TO with 15A NCAC 02C.0100 or 15A NCAC 01C-.0200 Well Conshuction Standards and that a
If this is a repair f H out known wen consh action information and explain the nature of the ropy of this record has been provided to the well owner.
repair underW21 remarks section or on the back of this form 23.Site diagram or additional well'details:
8.For Geo. robe/DPT or Closed-Loop Geothermal Wells Navin 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: SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths ifdi fereni(example-3Q100'roof 2@100D construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
i
11.BorehoIe 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: L` construction to the following:
(Le.auger,rotary,cable,direct pusl-4 etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS,ONLY: 1636 Mail Service Ce InIter,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: Ia addition to sending the form to
the address(es) 'above, also submit lone copy of this fomo within 30 days of
13b.Disinfection type: ( i Amount: completion of well construction to the county health department of the county
where constructed
Form OW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016