GW1-2022-00879_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor In rmation-
I
14:.WATER ZONES
FROM TO DESCR1PT10N r
well ConhactorN a it ft
Aft ft
NC Well Contractor Certification Number 15:OUTER.CASING,(fdr&ultiz:dised.'wells Oft LIlVER if'a livable'
Morgan Well &Pump, Inc. FROM I TO DIAMETER THICKNESS MATERUL
+1 ft ft 61/6/ &' sdr2l pvc
Company Name Qr— __ ��.� / I
{ -{�T( 16:INNER CASII�G OR TQBIIVG'gm eothermal clbsid,406• r`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits s(ce.b7C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17.-SCREEN..'.,'
Water Supply Well: FROM TO DIAMETER SLOT SIZE TnICKNESS FMATERIAL
Agricultural IMunicipal/Public ft ft in•
i Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft
:r18i GROUT
i Industnal/Commerciai Residential Water Supply(shared) "
:';
JIrrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
-'monitoring DRecovery ft ft.
Injection Well: ft ft
_I Aquifer Recharge �JJ Groundwater Remediation
19:SAND/GRAVEL-PACK if a`licalile r
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERTAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage : l_—
ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(atticli'additidri'sI sli'eed.ifiieceisi j'' =,. :` .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM a� DESC.RI.PTION(color,hardness,soil/rock ty e rain sire etc.
n' Q ft 4.Date Well(s)Completed: LPL Well ID# �. ft5a Well Lo tion: ftut �,Facility/ ner Name Facility ID#(ifapplicable) ft
p r�
n ft ft J
V Physical Address,4,and Zip ft ft
T lib lq
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^• 1 ' i
(if well field,one lat/long is sufficient) Qq 22.Certification:
315,9016 N
6.Is(are)the well(s)*Permanent or Temporary
Mil)
Certified Well Contractor Dat
is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or 4}No with 15A MCAC 02C.0100 or 15A NCAC 02C.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 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells consruction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7-0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example--3 rQ200'and 2 construction to the following:
10.Static water level below top of casing: t.le (ft) Division of Water Resources,Information Processing Unit,
1f water level is above casing,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 Oo lr q construction to the following:
(ie.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) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submitlone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016