GW1-2022-03088_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources •C Revised 2-22-2016
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