GW1-2022-01737_Well Construction - GW1_20220207

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:G
r Cn Q `C` �/1 C�V JG 14:.WATER ZONES,,*.
Well Contractor Name FR M TO I DESCRiPT10N .
��SSC'\ J ft 1 ft
y_ ft ft
NC Well Contractor Certification Number
15:OII7 ER ra cING:Adr rhw 'r sed wells)O}t LIFTER(if licible'
Morgan Well &Pump, Inc. FROM TO* I DIAMETER I TH1CIt`iIESS MATERIAL
��LI� +1 ft. ft. 61/8I in- sd21 pvcz <..
Company Name <...•.
1C'IlVNER CASING OR�TIJBI1Vt:.''eothermal'clo'sed-rod')'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(.e.LUC,Comity,State,Vw-iance,eta)- ft 8. in.
3.Well Use(check well use): ft .t. in.
Water Supply Well: 17."SCREEN'•:,:..:. `_;. . ..; _.:::.:.+:r:.•: ::•.::-.'..:._:.::.>•::?.. '�.
pp y FROM TO DIAMETER SLOT SrZE THICKNESS MATERIAL .
Agricultural rilMunicipalRublic ft ft in.
_:]Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft.
I lndustrial/Commercial E3Residential Water Supply(shared)
—!)Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
�-y ft. ft.
_J Aquifer Recharge 1�Groundwater Remediation
•.19:SAND/GRAVEL'PACK if a "licibli
Aquifer Storage and Recovery OSaiinity Barrier FROM TO MATERIAL EMPLACEMENT ilIETHOD
Aquifer Test DStormwater Drainage ft ft
Experimental Technology []Subsidence Control ft ft
Geothermal(Closed Loop) bTracer :20.DRILLING.LOG'(itticli'sdditiun'sl sikebif aecess'-':"E
Geothermal(Heating/Cooling Retum) 00ther(explain under#21 Remarks) FROM TO D CRIP ION(col r,hardness,soil/rock type in size,eta)
ftZAft.
4.Date Well(s)Completed: Well ID#
Sa.Well Location: .+� -I 6 Q ft Q ft n
mavkc
y/tJQ� Oft �D ft
Faciliy/ n Name Facility M#(if applicable) i46 ft
ft
Physical Address,City,and Zip
ft ft a
►L+W \� 21:I2EMARKS' `i -
County n Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fie one lat/long is sufficient) 22.Certification
3 . PI R57 N U, S"6,366 W G 4✓
� saz
6.Is(are)the wells)jpPermanent or OTemporary SiSi a�rr�itue of Certified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or Wo with 15.4 NCAC 02C.0100 or.15A MCA 02C.0100 Well Construction Standards and that a
Ifthis 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 construction details. You may also attach additional pages if necessary.
drilled: - % L1 Z 6 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'acid 1 /1010D construction to the following:
10.Static water level below top of casing: G U (ft) Division of Water Resources,Information Processing Unit,
If water 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 o"N construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
f LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: �4/1v�e_4 Amount: 1 �2i 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