GW1-2022-00915_Well Construction - GW1_20220107

Sr11t::Form _'
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor In or tion: .
14:.WATER ZONES
FROM TO DESCRIPTION r
Well CTntractqr Jame ft ft
osq?z - Aft ft
i
NC Well Contractor Certification Number 15;0UTER CASING,(&i riiulti� Sed wells)OR lMgER(if'a
Morgan Well &Pump, Inc. FROM I TO DIAMETER THICIavESS MATERIAL
+1 ft 116 ft 61/81 in. sd21 pvc
Company Name ���� �' ;
16 INNER C G OR TQBIIVG etithermal c1o'sed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(ie.f1IC,County,State,Variance,etc)- ft ft. in.
3.Well Use(check well use): ft ft �•
17:SCREEN'.:,:.
Water Supply Well: FROM TO DIAMETER SLOT srZE THICKNESs MATERIAL
_'Agricultural rilMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) IpResidential Water Supply(single) ft ft in.
Industrial/Commercial LYResidential Water Supply(shared) ,C :GROUT:
Irrigation FROM TO MATERIAL EMPL CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring Recovery ft ft
Injection Well: ft ft.
-I Aquifer Recharge dGroundwater Remediation
- 19'SAND/GRAYEL'PACK if a 'licibre -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL ENLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.'DRILLQVG.LOG'(itticli`additioaslslieetsifiiecess
FROM TO DESCRIPTION(color,hardness,soil/rock p e, in size,etc.
Geothermal(Heating/Cooling Reform) Other(explain under#21 Remarks) b ft Za ft d I V-
4.Date Well(s)Completed: 2 ( Well ID# 16 K 456 ft. r-o
5 ��ks
Location: ft ft.
:/M'{'i�1� Cos ft p oSft br
Facility/Owner Name Facility lD#(if applicable) SS ft Xcoft• AUL
ft ft J
ft ft
Phil Address,City,and Zip
3� '21:REMARKS"
County Parcel Identification No.(PII)
�s
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l �'
(if well field,one lat/long is sufficient) 22.Certification:
35 S�f23 N --Sa. 398� W
6.Is(are)the well(s)SPermanent or OTemporary Si a 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: Mil Yes or J@No with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standm-dr and that a
If this is a repair,fill out known well construction irfformation and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For A11 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 1 "`r L� construction to the following:
(ie.auger,rotary,cable,directpush,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) I d - Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit ione copy of this form within 30 days of
13b.Disinfection type Amount: 70 completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016