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HomeMy WebLinkAboutGW1-2022-03088_Well Construction - GW1_20220307 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I 1.Well ,Contractor Information: Cht�� Mori► 14:.WATERZONFS:'. : ':: r -!:' ..•�:.:=:r'':.,. .`. :'....:.i• We1lContractorName FROM TO DESCRIPTION —357Z-�4 ft 2ol ft ft ft NC Well Contractor Certification Numbet 15.0 UTER-CASING,foc multi rase&*6lls O 2 TT17NR(i' 'licahle'.; Morgan Well&Pump, I.nc. FROM, TO' DIAMETER: THtCKNESS MATERIAL +1 ft 6 ft 6 Val in, sd21 pvc Company Name / 16:INIQER CASING OR•TUSING: •eothe"r'malclo'sed-loo'i -''- - " ' 2.Well Construction Permit#: 16Z6 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits'd.e.M,,COnnty,State,Variance,etc)• it• ft in. 3.Well Use(check well use): ft % in. Water Supply Well: 17:SCREEN',:•'.: s::. . '�: ...__ _rt:. '..r-;:Y;;.- FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL. Agricultural uuicipal/Public ft ft in. Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft I Industrial/Commercial DResidential Water Supply(shared) :.'I8:GROUT:: t:: ; P Irri ation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: o ft 20 ft• bentonite poured Monitoring DRecovery ft. ft Injection Well: ft ft _ Aquifer Recharge t�Groundwater Remediation Recovery and g 'Aq �Y uifer Storage Salim Barrier FROM � t5r FROM TO MATERIAL EMPLACFMENTMETHOD . I Aquifer Test oStormwater Drainage M ft I Experimental Technology [3Subsidence Control ft ft Geothermal(Closed Loop) OTracer :20.tiRILLING.];OG'(atta li'addition'al sheetsjf fieeess"')''+.;':::3 l Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM D TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)ft ft /� OVa a 4.Date Well(s)Completed: Z 3-2Z Well ID# ft 54 ft. S S't'arlf'j 5/a.Well Location:a e'A s ft ZQ ft' J-3- `g6 n ft ft QtVI Facility/,OAkerNaam. �lFacilittylD#i(if aappl t applicable) ft f AV ft ft. Physical Address,City,and Zip ft ft -- -y 6 .- (_. County Parcel Identification No.(PAS sr fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) tsf}` <ar gt•S1 {( }A ^ I 22.Cer cation- r,.F . ffi v.t�Pa.) EM 95.?87627 N -9) . 066y 99 W Z 6.Ls(are)the well(S)6ermanent or DTeiporary Signature of C e ell Contractor Date [] Yes By signing this form,I hereby certify that the well(s)was(were)constructed in accordance J 1=_ 7.Is this a repair to an existing well: Yes or ON. with 15,4 NCAC 02C.0100 or 15A NCAC 62C-.0200 Well Construction Standards and that a If this is a repair,fill out known well construction biformation 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 constiuction details. You may also attach additional pages if necessary.. drilled: % SUBMITTAL INSTRUCTIONS 1 9.Total well depth below Iand surface: zzo (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: 30 (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 above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: L construction to the following: (Le.auger,rotary,cable,directpuslr,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) b Method of test: air pressure 24c.For Water Suauly&Injection!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 type: aV ►U 14L-W_ Amount: p dZ completion of well construction to the county health department of the county where constructed. i Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources •C Revised 2-22-2016 i i