GW1-2022-00868_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contactor Information:
14:..WATER ZONES:'.
FROM TO I DESCRIPTION
Well Contractor Name ft It.
[
3��a ft ft
NC Well Contractor Certification Number
15:OUTER-CASING,(foi•multi=rased wells O)_2 L11YER if a'lirdble
Morgan Well&Pump, Inc. A / FROM TO DIAMETER THICIQVESS MATEurex.
J�C 61/81 in. sd21 pvc:
CompanyName :.
136 a 1 IC INNER CASING OR TQBTNG' eothei�mal closed-lod'
2.Well Construction Permit#: FROM TO DIAMETER I TEICRIVESS MATERIAL
List all applicable well construction permits'(i.e.UIC,Cowity,State,Variance,etc.)- ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN--. .<. L
PP Y FROM TO DIAMETER SLOT SIZE TASgRPS MATERIAL
Agricultural n
j Muaicipal/Public ft ft
i Geothermal(Heating/Cooling Supply) aZesidential Water Supply(single) ft. ft
1 Industrial/Commercial DJ Residential Water Supply(shared) 18:GROUT.:':
;.
hn ation FROM TO MATERIAL I EEMPL.4CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 40 ft* bentonite poured
'.Monitoring Recovery ft ft.
Injection Well: ft ft
i Aquifer Recharge Groundwater Remediation
— :19:SAND/GRAVEL'PACK if a 'licatile
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology OSubsiderice Control ft ft
Geothermal(Closed Loop) Tracer :20.3)RU LING.LOG'(atticE-ddiddMil stieets.if
FROM TO DESCRIPTION(color hardness,soil/rock type, rain size,etc.
i Geothermal(Heating/CoolingReturn) J Other(explain under#21 Remarks) d
4.Date Well(s)Completed: 1L t—� Well ID# U ft fr' (OL*t-••
Sa. a Location: /I� o b ft �'tpft. K rya.
f y ! 16 1)VS ft ft
l� ft ft
Facility/Owner Names 11 L Facility ID#(if applicable)
S—Z,5 J L1�1"_ �� S S �;^ ft ft
Physi2 ddress City,and Zip ft. I ft
CtS 1'b^-- 2 �q? S7•�!S 21:I2E1�lARISs=
County '1 Parcel Identification No.(PIN) l'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lat/long is sufficient) 1
N --g�• ����ZS` w ��GCr�►s,e/' 2 Zeti(
6.Is(are)the well(s) ermanent or OTemporary Signature of C ed Well Contractor ate
By signing this form,1 hereby certify that.the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or awo with ISA NCAC 02C.0100 or 15A NCAC 02G.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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: - % zz SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 cd 00' @100D construction to the following:
10.Static water level below top of casing: U (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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: r Q 1 "/`�t Y q construction to the following:
(Le.auger,rotary,cable,direetpusb,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) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
. / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �G C Amount: Z completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016