GW1-2022-00859_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
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1.Wf1l CDZitractor Infra• ti P 7
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14.WATER ZONES
FROM TO - DESCRIPTION <
Well 3 Co tract ame ft ft Co
ft ft
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NC Well Contractor Certification Number 15:OUTER,CASING,(foc mniti�:rased wells)qR_LINER if'a livable'
Morgan Well &Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL
+1 ft. ft 61/81 In' sdr21 pvc
Company Name I INNER C G OR TUBING(•eotheivtal closed-lob r '"�- t
2.Well Construction Permit#: _ TO DIAMETERTHICKNESSTCI4VFSS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) FROM�ft _
ft in.
3.Well Use(check well use): ft in.
1 17.S
Water Supply
PP y Well: FROM TO I DIAMETER SLOT SIZE TFITCKNESS MATERIAL
Agricultural rilMunicipal/Public ft. ft in•
1 Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ft. ft
I Industrial/Commercial DResidential Water Supply(shared)
::18:GROUT..'.:.
Irrigation FROM TO MATERIAL Y EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
Monitoring DRecovery ft ft.
Injection Well:
_J Aquifer Recharge Groundwater Remediation
•.19:SAND/GRAVEL'PACK rf a •licibl'e
Aquifer Storage and Recovery OSalimty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
—i Aquifer Test OStormwater Drainage ft ft
'I EXperimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) O'Tracer :20.DRII,LING.LOG(atticli`additidtf I il;'eetsifiiececs'")':;'>` =::. :' :
I Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a in size,etc.
6 ft D ft dtr
4.Date Well(s)Completed:)Zl /d�7 Well ID# O, ft �6. ft
—T T� ft ft
5a.,Well Location: '(
OS' W s ft. .?f'�ft l r iL
Facility/O net Name f� Facility ID#(if applicable)'f p ft •r ft. ';': f�" k I
Ph / KZ90 ft ft 7 et 2 P
Ph ical ddress,City,and Zip ft ft J A N 1 202?
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3'5. 33�13 Nrga.�5�� W C.-� IZ �o Z
6.Is(are)the well(s)oPermanent or 13Temporary go a of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or JpNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "r (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2(a)100� construction to the following:
10.Static water level below top of casing: 4T) (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (71 Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection typ 6IN6 Amount: �Z aZ- completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ',I Revised 2-22-2016