GW1-2022-03067_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
W ontractor I tin:
V
'14:.WATERZONES:". - � :I_�'': ..�'..:�.;`•.
Well ntrac a FROM TO DESCRIPTION
ft ft
ft ft
Well Contractor Certification Number
15;OUTER CASING,(foi mniti=rased wells Oft LUQER if'a'livable i'..::'
Morgan Well&Pump, Inc. FROM I TO.' DIAMETER THICKNESS MATERIAL
Company Name +1 ft' O ft' 61181 I in' sdr21 pvc
n/ 16:71VNER C G ORTUBING. eutiiermalcIo'sed-lod' :
2.Well Construction Permit#: . FROM TO DIAMETER THICKNESS •MATERIAL
List all applicable well construction permits'(.e.VIC,County,State,Variance,etc)• fL I �'
3.Well Use(check well use): ft I f, in.
Water Supply Well: 11:SCRE EN'.:-:. .
FROM TO DIAMETER SLOT SIZE .THICKNESS I MATERIAL .
Agricultural nMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft
I Industrial/CommercialE3Residential Water Supply(shared)
::18:GROUT•.'?
i hri ation FROM TO MATERIAL - F lY1PI ACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentanite poured
'.Monitoring DRecovery ft. ft
Injection Well:
Aquifer Recharge )Groundwater Remediation ft ft
Aquifer Storage and Recovery Salini Barrier '19i S,ND/GRAVELTACK if a 'livable
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Qistormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(attacli'idditfiirisl slieetsjf ireces'sa il'y
Ii'Geothermal
(Heating/Cooling Return) �Other(explain under#21 Remadcs) FROM TO T DESC PTION color hardness,soil/rock type ` in size,etc)
ft. V ft. ,
4.Date Well(s)Completed ZZ Well ID# ft �a ft. rbW r\ 41%,rk—
ft. ft Wr rQG
ft aft 1 Lit-Facility/Owner Name Facility M#(if ap livable) ft ft
�7a1 �axr+�r 12.(3 Go �'d ��Z$�- ft ft
Physicai Address,City,and Zip & ft
;•-
county Parcel Identification No.(PIN) v MAR O _20
7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) Q 35 ?�(� 22. tification:
w L l
6.Is(are)the well(s)OPermanent or J Temporary ?With
ZICAC
ertified Well Contractor Date
sform,I hereby ca•tify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or SNo 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the natw•e of the copy ofthi.s record has been provided to the well owner.
repair under 421 remarks section or on the backaf this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUM$ER'of wells construction details. You may also attach additional pages if necessary.
drilled: .
O SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a/1 depths rfdierent(example-�00'mid 2@I00� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 'roY L�
above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,directpush,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
I
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
//�� ) O the address(es) 'above, also submit!one copy of this form within 30 days of
13b.Disinfection typ6✓k)C�'(lnr 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