GW1-2022-03075_Well Construction - GW1_20220307

wr LL C UNSTRUCTION RECORD (GW 1) For Internal Use Only: yT
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I.Well Contractor Information: i
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l Wet 14:.WATER ZONES::'. P
Well Contractor Name - FROM TO DESCRIPTION r
3S7 ` lafL
ft ft.
NC Well Contractor Certification Number
15:OU2'ER:CASING,for,multi=rased wells)bIt LIlgExt if' lleable'
Morgan Well&Pump, Inc. . FROM TO' I DSIil12ETER THIcifiVEss MATERLt•L
Company Name. +1 ft. ft I 6 1/8/ m' sdi21 pvc
16.INNER CASING OR•TUBING.'•etitlierma-rrlo'setL-led`:
2.Well Construction Permit#: 13 ys FROM TO D1
A1n&;j'ER THICKNESS Mi1T RTAr.
List all applicable well construction permits f.e.UIC�County,State,Ymiance,eta) ft ft, in.
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3.Well Use(check well use): ft
Water Supply Well: 17"SCREEN:
Agricultural 'ci al/Public Mom TO DIAMETER SLOT SIZE ~THICKNESS MATERIAL.
O M p ft ft. in.
I Geothermal(Heating/Cooling Supply) ' esidential Water Supply(single)
I Industnal/C°mmercial DResidential Water Supply(shared) ft ft. m.
I Ini ation 8:GROUT•:: -' :: '.: a.:.:.•:•: -
FROM TO MATERM.L EMPLACEMENTM A ETHOD& MOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
'•Monitoring Recovery ft ft
Injection Well:
J Aquifer•Recharge DGroundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier :.'19:SAND/GRAVEL-PACK if a"lica6lb _.;:_'::'•. •.:^, •':•.
FROM TO MATERTi1L EMPLACEMENT METHOD
Aquifer Test QI Stormwater•Drainage ft ft
1 Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRMZINGL'OG'(attach'addition'sls2iee6ifiieces's
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION wlor,hardness,soil/rock type, ' in size etc)
0 ft Orft.
4.Date Weil(s)Completed: 2•"� — Well ID# W., ft �S
Sa.Well Location: 6 ft S ft
ft ft
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Facility/Owner Name Facility ID#(if applicable) ft fL
5'Sl� ��ue Sk _ -q�( � C ZSO3� ft ft
Physical Address,City,and Zip ft. ft
21:3MM.ARKR'-
C011IIty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.C ' cation: ' �V'riai':.^•:�,t Pv'iI�
rr.ril,L vat Fv.a i i
6.Is(are)the well(S) rP-r...ent or oTemporary Si, a of Cert' ed W ntractor Date
By sio ring this form,I erebv ceii6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or j�Nlo with ISA NCAC 02C.0100 or 15A MCA 02C.0200 Well Consbvction Standm•ds and that a
Ifthis is a repair,fill out known well construction idformation and explain the natut•e afthe copy ofthii record has beenprovided 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 I GW-I is needed. Indicate TOTAL NUIvBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ y
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) 24a. For All Wells: Submit this foray within 30 day§ of completion of well
For multiple'wells list all depths if different(example-3�a�200'aiid 2Q100)
construction to the following:
10.Static water level below top of casing: '36) (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+"
11.Borehole diameter: 6 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
(in.)
24b.For Iniection WeIIs: In addition to sending the form to the address in 24a
12.Well construction method: r otn�L� above,also submit one copy of this form,within 30 days of completion of well
(Le._auger,rotary,cable,directpusk etc.) construction to the following:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (� Method of test: air pressure 24c.For Water Sunnly&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 type: uIR Amount: 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
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