GW1-2022-01742_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only: � +✓�xy
1.Weil tractor Info on:
'14:.WATER ZONES;'. - ''•' : 'i_:
Well Con c rN a FROM TO DESCRIPTION
ft ft
ft ft
NC Well Contractor Certification Number
l I5:OIITER�ASING,(foc multi=c ea wells)OR l2iER(if_-
Morgan Well&Pump, Inc. FROM TO DIAMETER THICKNESS MATERLI•L
Company Name +1 ft ft. 61/8/ In' sdr21 pvc
�r7 �r IC INNER CASING ORTIIBIIVG.''eotbearih l'clo'sed loo'
2.Well Construction Permit#: `'�" FROM TO DIAMETER THICKNESS •MATEI2LIL
List all applicable well caisn•uction permits r.e. C,Coa1ty,State,Variance,etc- ft ft
3.Well Use(check well use): fL It. in.
VGeothermal
pply Well: i7:SCREEN',.:. . -
:. .
LLra1 J MuniCi al/Pub1iC FROM TO DIAMETER SLOTSrZE THICKNESS MATERIAL
p ft ft. in.
(Heating/Cooling Supply) *Residential Water Supply(single)
ft Mal/Commercial DResidential Water Supply(shared) _
F— chnology
:...
tiOn FROM TO MATERIAL EmmWe CEMENT METHOD&.AMOUNT
ater Supply Well: 0 ft 20 ft. bentonite poured
oring Recovery ft ft.
n Well:
erRechaz e ft ft
g 0GroundwaterRemediation
er-Storage and Recovery 0Salinity Barrier SAND/GRAVEL PACK if a plica6 re)
FROM TO MATERIAL J EMPLACEMENT METHOD .
r Test OStormwater-Drainage ft ft
mental Technology Subsidence Control ft ft.
rmal(Closed Loop) OTracer :20.DR1LLIlVG.LOG'(attach`addition'alB iieeess rmal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(wloq hardness,saiUrock type,grrin size etc)
O ft ft
4.Date Well(s)Completed: Well ID# lrj ft -;� ft I
ft 35 ft.
ft D ft-
Facility/Owner Name �4 Facility M#(if applicable) M IT.
�k �= tx11 m. NrLz-oqk- f ft
Lpkysical Address,City,and Zip ft ft r r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
N W
66. s(Iss((aarrret••)---tthhee well(s)MPermanent or ��I Temporary yB .-nin
Cemfied Well Contractor VA512
Dat
is form,I herekv cert�that the wells)was(were)constructed in accordance
7.Is this a repair to an wasting well: Yes or �No NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
IJthis is a repair fill out known well construction information and explain the nature 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-I 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:_ `, (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells List a!!depths Lfdiffet ent(example-3(200'aid 2(a)100)
construction to the following:
10.Static water level below top of casing:_ o (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
12.Well construction method: (,I above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,duectpush,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) •3 Method of test: air pressure 24c.For Water Supply&Injection 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 typewwlkt, Amount:2� bZ 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