GW1-2022-00897_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Information: /
�� ' .14:.WATER ZONES
FROM TO DESCR1PTi0N
Well Contractor Name ft. i
� r C •ft r[
�J d ft u v ft
NC Well Contractor Certification Number
15:OUTER CASING',(fo�multi=cased wells)O$LIlVER if'a"livable';:::'.:.::'
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKYESS MATERIAL
+1 ft ft 6 1/8/ in.
sdr21 pvc
Company Name 6/ FROM TO DIAMETER THI
.�, I�1 V O
W 11 16:'AVNER CAS MG OR.TQBING''eotliermal closed lod'
2.Well Construction Permit#: CKA'ESS - MATERIAL
List all applicable well construction permits(fe.UIC,County,State,Ymiance,etc) ft % in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN'.::. .
PPY FROM TO DIAMETER I SLOTSTZE I THTCRNFSS I MATERIAL
Agricultural DMurlicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft. ft in.
Industrial/Commercial DResidential Water Supply(shared)
!It-ligation FROM TO .MATERIAL EMPLACEMENT METHOD&"AMOUNT
Non-Water Supply Well: o ft 20 ft' bentonite poured
Monitoring QRecovery ft ft.
Injection Well: ft ft
_I Aquifer Recharge ril Groundwater Remediation
,:19:SAND/GRAVEL-PACK if ic`livable "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT 1AETHOD
Aquifer Test C)Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.:DRII.LING.LOG'(atti6'sdditidn'al slieets
l Geothermal(Heating/Cooling Return) Other(explain under#21 Rp!rarks) FROM To DES [PTtoN color,hardness soft/rock a in size etc
b ft D ft. ej D_d-
4.Date Well(s)Completed: 1I " Well ID# v ft. d ft c b
5a.Well Location: o ft ft ✓ -S�~
• I ft ft
Faci ty/ r Name _I y,`Facility IDI#(if applicable) ft ft
�ioo[ VlVdIn,C. 6-, l/1oicot14y0� ft ft !'
I/,:,
Physical Addres City,and Zip S ft. ft
_.
A La
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long� is sufficient)
a C� 22.Certification: t�56 { 17 (i N — O�.Z-21 O �� W �� ZS ZO
Sign a of Certified Well Contractor Date
6.Is(are)the well(s)�Permanent or QlTemporary i
By signing this form,1 hereby certify that'Ithe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or Wo with 15A NCAC 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 421 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: -ZOO SUBMITTAL
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@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 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 `�i Y L� 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)
Q Method of test: air pressure 24a For Water Supply&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: AA01&X Amount: ` V� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016