GW1-2022-10742_Well Construction - GW1_20221208

V&LL CONSTRUCTION RECORD (GW-1 For Internal Use Only:'
c ormation_
1.Well Contractor Inf
n L fr 1✓ o- •14:.W-A ZONES-,'.
U ` •.
S - FROM TO • .DESCRIPTION
Well Contractor Name ft ft
®� ft. ft
NC Well Contractor Certification Numbet 7iT DUxE& �CG.( "r mu]fi=rasefi sYells)OR LII3ER Cif a'lic2ble)'S :`.:
FROM T DIAMETER' TFIICF�ESS' MATERIAL
Morgan Well &Pump, Inc. +1 ft ft. sire/ �' aa21 pvo
Company Name /I� ft.J6.RgtMR CASNG OR•TIIBII� THI(SO7E55 MATERIAL
TG.' edth'erinaZ clo'ser11o6'
2.WeIl Construction.Permit�: / �w N `/ FROM TO DIAMETER� in.
EW all applicable well cansiruciionpermiis e U1C,Courriy State Ymima a etCf
ft. ft m• .
3.Well Use(check wen use): :,• ;•:•:,: •: .;:.:':.`Y:a�:"�.?.. ='•
VAg&Ulfural
pply Well: FizoM To DL4hIE1ER' SLOT SIZE TEHUI I SS hIATERZAL.
mal(Heating/Cooling Supply)- esideniial Water Supply(single) ft ftal/COmmercial E3Residential Water Supply(shaT4
FROM TO j ,MATERIAL'•: . EMPLSCEMENTMETHOD OUNT
&AM
•,Ism ation '
0 20 f-• bentonite• poured
Non-Water Supple Well: ft
Monitoring Recovery ft ft
Injection Well: ft ft . .
_!Aquifer Recharge K!GroundwaterRemediation SAND/GRAVEL'PACK(if a"IicaSYe ':.:y:
i S sler FROM TO MATERIAL • EMPI ACEIdEIVT METHOD ~
f Aquifer Storage and Recovery alini YBa
i Aquifer Test OStoimwater Drainage ft ft
I Experimental Technology Subsidence Control ft
i Geothermal(Closed Loop) �IT7acer :F0.DRILI�IGLOG'(ittach adtiitionEl DN eats ,h2rds"'soil: era`�etc)
FROM TO DESCRIPTION(color,hardnes,soillrocktppe,e
i Geothermal(Heating/Cooling Return) ri
10ther(explain under r 21 arks) fL /OfT.
i
4.Date well(s)Completed: WeIl1D#/ e1 16
L
-�/-2 �d L✓ �+Y �-
Sa.Well Loration: � �
Facility/Owner Name Facility ID4(if applicable)
Ina
Physical AAdress,City,and Zip - __ - -
6 yS�s� �_^ F
`:i"..-;: ..:..`_><:_�:-.,• _.,•
County PatcelIdentificationNo.(P]1D IR+vI a.+ -
w13at�:•u�s�
5b.Latitude and longitude in degrees/minutes/seeonds or decimal degrees:
(ifwell field,one hditng is sufficient) ' 22.Certification:
97SGf 2�p Lr ylr /U6(/GL/"r�4/ Z� za zZ
Date
6.Is(are)thewell(s) er
Signature of Certified Well Contractor Pmanent or O!Temporary
�° By signing this form,113erebv tang that the weR(s)was(wa'e)constructed in accordance
7.Is this a repair to an existing well �J Yes or° I No with 15A NG4C 02C.0100 or J5ANCAC 02C,0200 FPeII Construct"
and that a '
copy ofthis retard has beenprovided!o the well owner.
Iftl&is a repair,fill out known well consbuctGn information and explain the natw-e of the .
repair under 421 remark 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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details.'You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'ofwells
drilled- U SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For AN Wells: Submit this foDn within'30 days of completion of well
For molt pre wells list all depths ifdifferent(esmuple-3 a 00'and 2Qa 100) 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 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a.
® ,l above, also submit one copy of this fain within 30 days of completion of well
12.Wen construction method: a construction to the following:
(t.e,auger,rotary,cable,d rectpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WRILS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
132.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit One copy of this folm within 30 days of
13b.Disinfection type Jy1 0.!" Amount U completion of well construction to them county health department Of the county
where constructed.
Revised 2 22 2016
Form GW-I North CarolinaDeparhnent ofEnviromnentai Quality-Division of Water Resources