GW1-2022-01739_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ntr ctor Information:
14:.WATER ZONES
Well Contractor Nsd
FROM TO DESCRIPTION
M %ft ft.
NC Well Contractor Certification Number 15:OUTER CASING,(foc multi=cased''wells OJ2 LIlgER if a"'linable
Morgan Well&Pump, Inc. FROM TO DIAMETER THICKNESS I MATERTAI.
+1 ft- ft 61/8/ tn' sd21 pvc
Company Name .. ::.
Q ICINNER CASING OR TIIBING.' entfiermal closed lod'
2.Well Construction Permit#: .] l� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'�.e,UIC,Cowity,State,Ymiance,etc) ft. ft in.
3.Well Use(check well use): ft ,t. in.
Water Supply Well: 11-SCRFEN'.:•
FROM TO DIAMETER I SLOT STZE I THICKNESS ttiIATERIAL .
Agricultural �f Muaicipal/Public ft ft
i Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft in.
-Di Industrial/Commercial E3Residential Water Supply(shared) _.:. :.:.:...:..
18:GROUT::." .:, ....- .-. ..:....
Irrigation FROM TO MATERIAL E1\0L,4.CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonfte poured
'•Monitoring Recovery ft. ft.
Injection Well: ft. ft.
-.J Aquifer Recharge QGroundwaterRemediation
•:19:SANDlGRAVEI,'PA4K rfa '•lidtili:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwatei Drainage M ft
]Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) (Tracer 20.DRMIONG.LOG'(itticti'sdditidn'al sheetsif
I Geothermal eating Coolie Return) i FROM TOItoy
SCRIPTION(color,hardness,soillrock type in size,etc)
(H a/ `gI`Q ') _Other(explain under#21 Remarks) ,� � n^
4.Date Well(s)Completed: hq I Well 1D# ft. �-+ YbASML y*-WellLosori�_
3S � OVJn•
O ft ft
Facility/Owner Name G `1Fa`cility ID#KG
plicable) I ft ft
k u.air��AWN `� 7 ft ft
sical Address,City,and Zi ft ft
��� Ob 21:REMARILS :,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
. ' 22.Certification:N
6.Is(are)the well(s)Jp Permanent or [3Temporary Si f Certified Weil Contractor e
signing this form,Thereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or INNo 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 natw•e 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2LO (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdilerent(example-3Q200'and 2@100� 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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection 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:etc.)
L construction to the following:
(i.e.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) , J - Method of test: air pressure 24c.For Water Supply&Iniection 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: "U 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