GW1-2022-03065_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only: I
I.Well Contractor Information:�+1f1 9 CI 4'_J`'JV 14:.WATER ZONES
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Well Contractor Name FROM I TO DESCRIPTION
^' ft � ft
(�` J /•� ft I ft
NC Well Contractor Certification Number
I5:OUTER CASING,for mnlfi=rased wells OR L•I . (ifa-'livable'
Morgan Well & Pump, Inc. FROM T DIAMETER THICICMS MATERIAL
Company Name
+1 ft f 61/8/ m' sd121 pvc
� 1
O L/� 1L 16:7NNER CASING OR TUBING:'•e6thermid closed loo'
2.Well Construction Permit#: ` FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits'C.e.VIC,County State,Variance,etc.)- ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
17:SCREEN',:•:. ':.,. :•. .. °_ .:,;:,.:. ;r.-
t:ROM TO DIAMETER SLOTsrzE THTCKNFSS KMATERTAL .'
Agricultural MunicipaUPublic ft. ft in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single)R ft. R
I Industrial/Commercial Residential Water Supply(shared) :18:GRODT::
S hri ation FROM I TO MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• bentonite poured
•Monitoring DRecovery ft ft.
Injection Well:
[—,{[I ft ft
lGeothermal
Aquifer Recharge 1 Groundwater Remediation
� •:19:SAND/GRAVEL'PACK if a'licahle ...::.. -'�;.'=:
Aquifer Storage and Recovery ='Y Salinity Barrier FROM TO MATERIAL EMPLACEMFSVT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG attii Y dditidn'sls'ieefs.ifnecess ")'{;(Iieating/Cooliag Return) J Other(explain under#21 Remarks) FROM TO DF.SCRIPT ON(color,hardness,soil/rock type,grain size eta
I---'
v ft ft b,r4'
4.Date Well(s)Completed: o` Well ID# ft ft
5a.Well Location:
�/ ,l- qV ft � ft
r k I '�+�/1 S O n fc ZU ft &
Facility/Owner Name Facility ID#(if applicable) 22a ft %d ft
1761 6wmdn '/-J66t zrc_ ft ft
a _
Physical Address,City,and Zip ft. ft p
Ccb�,�r�S �"" 21iRFMARTIC` - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Pm �z „
die V.:. i
well\Ffield,one lat/lona is sufficient) //��/�1 \//� 22.Certification: tt,yw�A;4n t+ TCESS''?;I11{
-N V O, �v qI r,.i li,�'ivAi,Y t�IItti..).i �:,lL
W lam_ Ci.7 /j, Z�
6.Is(are)the well(s) Permanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or e§No with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction SYandewds and that a
If this is a repair fill out known well construction information and explain the nature ofthe 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: - t1 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-3 a@200'and 1Qa 100� construction to the following:
10.Static water level below top of casing: L (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: LI construction to the followin
(ie.auger,rotary,cable,direct push,etc.) g'
f
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&Infection Wells: In addition to sending the form to
{y^J /C / 1 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: W Amaunt: Y d completion'of-well construction to the county health department of the county
where constructed.
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016
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