GW1-2022-03087_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1.) [For Internal Use Only: C
1.Well Contractor Information:
/ S 14:.WATER ZONES ;
'Well Contractor Name FROM TO I DESCRIPTION
3S7Z.-A W ft ft
_ it. ft. I I
NC Well Contractor Certification Number
15:OUTER;CASING,(foc mnlfi ease3 wells)OR LIIQEIt(if a'licahle'•^,
Morgan Well&Pump, Inc. - FROM TO DIAMETER. THICIGVESS MATERIAL
Company Name +1 ft {5 R 6 1/8/ 1 lio' I dr2l pvc
�� I� 16 R CASING OR•TUBNG.'•eotheknmal elo'sed 166"?. :•"" :7''•
2.Well Construction Permit#: _ 5 , FROM TO DIAMETER; THICKNESS MATERIAL
List all applicable well construction permiis'(r.e.WC,Cowrh,State,Variance,etc.)- M R• in.
3.Well Use(check well use): ft 'n'
FROM TO DIAMETER' ::. - a •
Well: 17:SCREEN•,:r
Water Supply We '.: :. . .: ..•_ . .:r..•:�:. ,::.,,.; -.-.,.. . •F.:.. ..-.
SLOT SIZE TTICKMS MATERIAL.
Agricultural QM cipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) • esidential Water Supply(single) ft• ft in•
I Industrial/Commercial Residential Water Supply(shared)
GROUT-
.
hri ation FROM TO MATERIAL EMPI-4CEMENT METHOD&AMOUNT
Non-Water Supply Well: o ti• 20 ft bentonite poured
Monitoring DRecovery ft ft.
Injection Well:
1 A uifer Recharge ft ft
__ 4 g �J Groundwater Remediation
infer Storage and Recovery '19.SAND/GRAVEL'PA:CK if a"liable.•'• ='
A q g ery OSalinityBarrier• FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test DStormwater Drainage ft. ft
i Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.�RILI;MGSAG•(attacli'sdditional sheefs•if ue 'ces's -':;` F'•`.-.,
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain siu,etc)
0 ft q0 ft
4.Date Well(s)Completed: Well ID# (` ft. g!, ft.
5a•Well Location: 6 M y Q S dift 41
90M, G el&s ft. ft
Facility/Owner Name Facility M#(ifapplicable) R R• =
k•
121
22y Old 4%,16 �. Wk%, Al(, WG y ft ft. s �... art'
Physical Address,City,and Zip ft ft
�tps� 36Nfi-5�- gZ 21: :.. :- -
J. -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22 C Cation:
5,3 N - 1 MA24 8 W Z--y 22
6.Is(are)the wells) 'Permanent or Temporary Signature of Certifie Well Contractor Date
By signing this fo m,I her•ebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or dNo with 154 NCAC 02C.0100 or 15A NCAC 02C,0200 Fell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 land surface: "[� (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/C3a,200'and 2@100) construction to the following:
10.Static water level below top of casing: �6 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casi»g,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe 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: r Y L� construction to the following:
(Le.auger,rotary,cable,direct pusli,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) G. - Method of test: air pressure 24c.For Water Supply&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 e: Amount: d2- 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 .j Revised 2-22-2016