GW1-2022-01740_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW 1) HyHintform
For Internal Use Only:
1.
W Contractor Information:
T -14:.WATER ZONES
Well Con cto Name FROM TO DESCRLPTION c
ft ft.
NC Well Contractor Certification Number ft {t
Morgan Well&Pump, Inc. 15;OUP'ENCASING',({ocmniti=raseawells)ORT�TER(if -'licable'
FROM O" DIAMETER THICK�'i ESS MATERIAL
Company Name +1 ft ft 61/8/ in' sdr21 pvc
Ci(j ]PIl�TER CASITTG OR•TIISING.'"eotfiecmal"cio'sed lod
2.Well Construction Perm 16.it#: jj, FROM TO DL4METER THICKNESS ` 'MAr�uinT List aII applicable well construction permits r.e,£IIC,Comity,State,Ymiance,etc) ft. g
3.Well Use(check well use): ft ft
Water Supply Well: 117SCREEN',:,'. .::;':-. .`.�< .;.•,._.,:.:.,. :..,.
Agricultural MMunicipal/Public FROM TO DIAMETER
ft ft in. SLOT SIZE I.THICKNESS MATERIAL .
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single)
l Industrial/Comercial Residential Water Supply(shared) f t ft in.
m
E hTi ation ::i8:GROUT.'• r
FROM TO -. M,QTERrAL 1 EMPLACEMENT METHOD&_4MODNT
Non-Wafer Supply WeII: o ft 20 ft
Monitoringbentanite poured
Recovery Injection Well;
Aquifer Recharge nGroundwaterRemediation ft ft.
Aquifer Storage and Recovery of Salinity Barrier 19'SAND/GRAVEL-PACK rf a"lica6le ".
NT METH OD
_Aquifer Test QlStonnwater Drainage �FROM ft TO MATERIAL .EMPLACEMEft.
Experimental Technology D Subsidence Control
ft ft
Geothermal(Closed Loop) OTracer
20.DRII,LTNG.I;OG'(attacii�ddition'al slieets,if'aecess
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(-Io,hardness,soillrock r
. � ft-
Well e,gain size,etc)
�� ft
4.Date Well(s)Completed:
ID# �� ft' 3 b�vwh �r
Sa.Well Location: ft.
3 ft ft ,C)rbw
ZGOft �Jt. IfQY1l
Facility/Owner Name 55 ft-
Facility lD#(if a)plicable) ft ft.
-135 ft.
PhY1ca1 Address,
City,and Zip ft.b� GfC�/lY ��, `21sI2EM1,RIfS'- ft-
County Parcel Identification No.(PIN) .O 7^ 02
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
('dwell field,one lat/long is sufficient)
3 /ph N �'��. 't 22.C tification:
6.Is(are)the well(s)f Permanent or Temporary Signatur of it ed Well Contractor
Date
By r ring is form,I herebv cer4�that the wells)was(were)constructed in accordance
7.f Is this a repair to an existing well: �'Yes or No, with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and than a
If this is a repair fill out known well construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.
onal
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yo u maySite diagram the ba k oftithis page to-provide additional well site details or well
Yo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y
9.Total well depth below land surface: ZooSUBMITTAL INSTRUCTIONS
(ft) '
For multiple wells list all depths if different(Example-3 a 00'and 2@100) 24a' For AllWeHs: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below tap of casing: (ft)
IJwarer level is above casi,:g,use"+" Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: { ()ALI�r L� above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push etc.) construction to the following:
mma
ELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water SuDDIy&Injection Wells: In addition to sending the form to
GJ�' �Z the address(es) 'above, also submit one copy of this form within 30 days of
0�t 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