GW1-2022-03077_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
�hnS /�Qrt •14:.WATERZONES:C. , `:•: : f
Well Contractor Name FROM T I DESCPJFT1or4
G ft h I ft.
35�2-A ft ft
NC Well Contractor Certification Number
OUT'ER:C6.SINCr,(foc multi=cased wells O�tTTNF.R lfa-'licahle'..�:
Morgan Well &Pump, Inc, FROM TO' DIAMETER THICSiVESS MATERIAL
+1 q$ ft 6 1/81 m' sdt21 pvc
Company Name _
l ^J� 16:hVNER CASING OR•TUBI14G:'-eutlie'r'taal•clb'sed-Ion' . - -•
2.Well Construction Permit#: ` I ` ( FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(c e.WC,Comity,State,Variance,eta)- ft ft in.
3.Well Use(check well use): ft ft' in.
IVS
Water Supply Well: VROM
O. DIAMETER SLOT SIZE TAIC[QQFSSt rMATERIAL
Agricultural 0i Municipal/Public ft It. in:
Geothermal(Heating/Cooling Supply) W.idential Water Supply(single) ft ft
I Industrial/Commercial Residential Water Supply(shared) _.:
18:GROUT•:: "; :::=. :,:= L'.: >• ,:.: ;,'
I Irrigation FROM TO MATERIAL - EMPLkCEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
Monitoring []Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge �Groundwater Remediation r
Aquifer Storage and Recovery :.�:SAND/GRAVEL•PACK if a'•liable ':.:;: : :...._ .... •..;-. ;': ::.`
4 g ry Salinity Barter FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft Ft
I Experimental Technology Subsidence Control ft ft
1 Geothermal(Closed Loop) OTracer :20.tiRILL1NG.T OG'(attacli'additidn'sl s�eetsjf
Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, yin size,ete)
d .ft So fL 6lrewvX C�a►,.
4.Date Well(s)Completed: Well ID# 3 ft 65 ft. t3Vsi._ 54
5a.Well Location: 66 ft etb ft. (�(/
Al`est 5 R 1 1' R ft L GCS/w ft ayom VAW1
Facility/Owner Name Facility ID#(if applicable) ft ft.
g a( o"'(at me- ft ft
Physical Address,City,Jad Zip fL ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' CatiO : C 'v�u 4
u . yH 6 b 'N '$I•I76S66 �'" '- �RITI
l-ZZ
6.Is(are)the well(s) 'Permanent or OTemporary Signature of 671fied.Well Contractor_ Date
By sio ring this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 'QYes or To with 154 NUC 02C.0100 or 15A NCAC'02C-0200 Well Construction Standeuds 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:__ % SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 2o0 (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 2Q100D construction to the following:
10.Static water level beIow top of casing: W (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,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
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r� �LI construction to the following:
(Le.auger,rotary,cable,duectpush,etc.)
Division of Water Resources,Underground Injection Control:Program,
FOR WATER SUPPLY WELLS-ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 3B Method of test: air pressure 24c.For Water Supply&Iniectioni 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: 0A,,,wu Amount: d OZ 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