GW1-2022-10828_Well Construction - GW1_20221209

'SELL CONSTRUCTION RECORD (GW�-1) •For Internal Use Only, '
1.Wen Contractor Information: '
~V •14:,1ATER ZONES
Well Contractor ante M ft
FROM TO DFSCRIPTION c
tl: ft
NC Well Conhactor Certification Number 15.OD tER:f3ASING,(io"r tnnlfi-r26� �T)OR LII I> C�a Ticahle)'a =:•.•
Morgan Well &Pump, Inc. FROM TO- DIAnti TER 1 THICKi1TFSS MATETAS
+1 ft fi 1/81 6m sdt21 PVC
Company Name I6.Il CASIPTG 012•T[IBTNG' e6tIieirmal closed lod" ?.:::'' - ::%"
OM TO DLUSTERTsa�S
2.Well Construction Permit 5 �. �Il7 FR in' j
List all applicable well construction.P=nits'(Le.WC,County,State,Yaaa-A etcr ft" ft
k
ft ft m
3.Well Use(check well use): ,: r :•
Water Supply Well: FROM I To DIAMECER SLOT SIZE y TMCHNESS MATERIAL
-_Agricultural DMunicipal/Public it ft. m
Geothermal(Heating/Cooli og'Supply) Wesidential Water Supply{single) ft• ft. in.
I ustri CommercialLilResiamnal Water Supply(shared) =-:i' -•::: ::'? { ":' :'
TO
lIni on FROM MATERLiL EMPL4CEMENTMETHOD&AMDIINT
Non-Water Supply Well: o ft 20 ft Benton@e• poured
2MonitoringRecovery ft ft
Injection Welh ft ft
J Aquifer Recharge D1 Groundwater Remediation. :; .•.: '-,".
79:SAM/GRAVEL'PACK tf ' 'linable '
Agnifer Storage and Recovery r1SalinityBarrier FROM TO
i
q MATERIAL EMPLACEMENT METHOD
A ufer Test k Storm ft.water Drainage ft
i Experimental Technology Subsidence Control ft ft,
i Geothermal(Closed Loop) Tracer :ZD.DRILT�4GS OG'(attach-additional sheetsjfaeces
FROM TO DESCRIPTION(coin,hardness,soilfmck type, r grainsize,etc)
r 1 Geothermal(Heating/Cooling Return) J Other(explain-under#21 Remarks)
4.Date Well / ✓s)Completed: 6 ` 1,ell IDS' �B N
5a+ ]ffJ.�•7W�ell Location:
1 N /✓/Q J' W J
. !f ft ft
Facility/Owner Name / �( p Facility IDS(if applicable) n ��- al
ft ft
Physical Address,City,and Zip ft ft 2022�
County Parcel Identification No.(PIlq)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
�o�a N 9 1jO5aX
S' of Certified ell Contractor � •Date
6.Is(are)the wells) Permanent or OTemporary
By signing this form,I luaeby ciu#51 that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well• Dyes or WWj 1SA NCAC 02C.0100 or!SA NCAC 02C-.020D FPeII Construction Standards.and that a
Ifthfs is a r•epan,fiII out)mown weR consbxnciion info matio and N L do the nature of the copy ofihis record has been provided to the well owner.
repair under 421 remarks section or on the bark of this form 23,Site diagram or additional well details:
You may use the back of this page to piovide 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 NLIMER'of wells
drilled: S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2Z0 (ft-) 2,42.For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells llst all depths ifdifferent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: �O (ft-) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (m•) ) 24b.For Iniection*ells': In addition to sending the four to the address in 24a
1,- above,also submit one copy of this form within 30 days'of completion of well
12.Well construction method.- CO3 construction to the following:
LA
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Centro)Program,
FOR WATER SUPPLLYY WEL—q.ONLY: 1636 Mail Service Center,!Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuDuly&Iniection Wl lls: In addition to sending the form to
G Q the address(es) 'above, also submit one Icopy of this form within 30 days of
13b.Disinfection type• ,� 'Amount: I completion of well construction to the county health department of the county
where constmated
Revised 2 22 2016
Forth GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources -
I