GW1-2022-03078_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C�•rl s /Koro►ay 14'..WA.TERZONES:'.
Well Contractor Name FROM TO DESCRIPTION
3572_A w ft ft
ft ft. j
NC Well Contractor Certification Number 15:OUTER;CASMG,foi mul&ciised wells)OR ENFR if a
Morgan Well& Pump, Inc. FROM TO DLSMETER TEC10KNESS MATERIAI
+1 ft 95 ft 61/8/ in. sd21. pvc
Company Name
ICINNERCASINGORTUBIlVG.''eotlieimardosedrod' "'•a• <;
2.Well Construction Permit#: 13S?3 FFTO DIAMETER THICKNESS MArTei.
List all applicable well construction permits'(:.e.UIC,County,State,Variance,etc) ft in.
3.Well Use(check well use): ftin.
Water Supply well: EN.TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
!Agricultural �M 'cipaVPublic fti Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft
I lndustriaUCommercial Re Residential Water Supply(shared) .18iGRODT:=..
E Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
'•Monitoring DRecovery ft. ft.
Injection Well: ft ft
_!Aquifer Recharge �Groundwater Remediation
!:19:SAND/GRAVEL'PACK rf a"lica6le ' '' � ' •'
Aquifer Storage and Recovery DSalinity BarrierFROM TO • MATERIAL I EMPLACEMENT METHOD
I Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer :20..MRE=G.LOG'(attiiiEj dditional slietsjf necessa-)':�: "'•`.,=s :-
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
d ftj f ON�r.►'L-
4.Date Wells)Completed: Well ID# 6 ft Za ft.
Sa.Well Location: �d ft ft. v
/ it. Ym ft e
t Ge'05
Facility/Owner Name Facility M#(if applicable) M f
t.
GC—�� Q�� C'*0.r�1 K 1�5+• ���a.5r 1`L ft ft.
Physical Address,City,and Zip ft ft
21I2Ga 3W,6-5b-19SZ = .. .
County Parcel Identification No.(PIN)
• I MAR 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.C ratio
35 3g7Z 11 'N —V-195923 w t�` ��{ !yam q/
F,'. °rf1tOPf:frLti7o-1affl2�z2.
6.Is(are)the well(s) ,Permanent or Temporary Signature of CertiEed WoU.9off5ictor 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 No with 154 NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
If'this is a repair,fill out known well construction itiformation and explain the natw-e ofthe copy ofthis record has been provided to the well omier.
repair under#21 remarks section or on the back of thisform. 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: L400 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 6o (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: m 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: CO L� i
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
N
13a.Yield(gpm) Z Method of test'air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit bnb copy of this form within 30 days of
13b.Disinfection type: r^V1V'`f*-A Amount: IL 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
i