GW1-2022-00860_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Inforrmaation:
11(1 y `1 &JA t
14.WATER ZONES r
—may- FROM TO DESCR1PT10N
Well Contractor a ft ft I
2zA ft ft
NC Well Contractor Certification Number 15:OUTER CASING',(&n multi-rasea wells)OR IDMRlieable'v
Morgan Well &Pump, Inc. FROM To DLALMETER THICKNESS MATERIAL
+1 ft ft. 6116/ in' sdr21 pvc
Company Name
�� 16:'INNER CASING OR TUBING'•eothei�mal
20` closed-loo• r
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(te WC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft in.
Water Supply Well: 17:SCREEN'.: . .;.
PP Y FROM TO DIAMETER SLOT SIZE THTCKNESS MATERIAL
Agricultural rilMunicipal/Public ft ft in. -
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft ft in.
i Industrial/Commercial DJ Residential Water Supply(shared)
,:18:GROUT:: -
hri ation FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft .bentonite poured .
'.Monitoring [)Recovery ft. ft.
Injection Well: ft ft
-I Aquifer Recharge QGroundwater Remediation
19:SAND/GRAVEL'PACK rf a`licatire ''
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) [ITracer :20.tiRILLING.I OG"(attacli`sddition'sl sli'ct sjf iiecess" _. .` ,:::•-:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,ha ess soiUrock grain svr,etc
O ft 'D ft
4.Date Well(s)Completed: Well ID# `d. ft s} ft Mlt
Sa. ell Location: a,� ft It
Facility/Owner Name 7, Facility
ID4(if appliiccaabblle�)�_� ft ft \ _ ,
ft ft
Ph ical Address,City,and p ft ft 7
.-
Q.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35,�65 l N g0 .(el l$ W —� 1 Z 11,6 kv
6.Is(are)the well(s)*Permanent or MTemporary Si&e f 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 J*No with 15ANCAC 01C.0100 or 15ANCAC!02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain Are nature ofthe copy ofthis 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 1 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: 760 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: ! A) Division of Water Resources,Information Processing Unit,
If water level is above casino use.'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6 (in.) 24b.For Injection 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: r O r 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) 2 Method of test: air pressure 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
�y�,.�� ^^��� the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type•6Ar�i' e, Amount: o" 07- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016