GW1-2022-01743_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W or Informafi
14:.WATER ZONES,_ ,.
11 FROM TO DESCRIPTION `
Well Contras N e ft ft
01
ft ft
Well Contractor Certification Number 15.0 II1ER-CASING,(foi'multi=rased-wells Oft IIIVL�(h a licable
Morgan Well &Pump, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
+1 ft. ft- 61/8/ in' sdr21 pvc
Company Name
qL 16:TIVNER CASING OR TIIBING rm eotheal closed loo'
2.Well Construction Permit#: D FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(County,State,Variance,etc-) ft ft, in.
3.Well Use(check well use): ft ft in.
1'1:SCREEN.:,:.
r.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft in.
il Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft g• in.
i Industrial/Commercial DResidential Water Supply(shared) ,'18:GROUT.'.
!Ini atiOn FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft* bentonite poured
Monitoring DRecovery ft. ft
Injection Well: ft ft
_I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if a ' IZ777.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
_l Experimental Technology [3 Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRU LING.LOG(kttidi'sdditidn'al sli'eefs if riecess"')+;
FROM TO DESCRIPT ON(color,hardness,soil/rock e, rain size,ete)
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) -6 ft ft
ir
4.Date Well(s)Completed:I 2 12Z Well ID# ft. 26 ft
�a.Well
LosAk,,!)
ft 5 ft
JL._r ¢tom ft �t. J J ft. ft.
�}F�ajciliCty�/�OwnerName �1 Facility
CID#�(if applicable)
�
1J ✓✓ { �la N� LTV ft ft.
Physical Address,City,and Zip ft ft
2�221:REMARxs'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) a 22 rtificatio
3S_5A35 N �43C) . `�� W i 15
6.Is(are)the well(s)JlPermanent or OTemporary
Me e of Certified Well Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JpNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standm-ds and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of thii record has been provided to the well owner.
repair under 01 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:IV 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and @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 casing,use"+" :r , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells In addition to sending the form to the address in 24a
r Y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ! O LI 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) 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 typ : 1 Amount: completion of well construction tol 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