GW1-2022-03102_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14:.WATER ZONES a. :.: ;I:•. r
Well Contractor
,Naame FROM TO DESCRIPTION
LI S�Jory-A
ft ft
NC Well Contractor Certification Number
15:OUTMRASING,(fo"r multi=cased wells OZt LII It R if a-'livable'•y "'.;:'
Morgan Well &Pump, Inc. FROM I TO' DIAMETER TEaCHNEss I MATERIAL
Company Name +1 ftq_S ft. S 1/S/ in' sd21 pvc
P Y n ^� 16:INNER CASING OR•TIISTNG.'i 6th*4inal elo'sed-lou' = ;
2.Well Construction Permit#. s / FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits'(1.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft• in.
WaterSupply Well 17_'SCREEN',:•:. .
FROM TO DIAMETER SLOT SIZE •THICKNESSI MATERIAL
Agricultural QMunicil/P Municipal/Public ft ft- in.
:—)Geothermal(Heating/Cooling Supply) Mesiderutial Water Supply(Single) ft. ft in.
I Industrial/Commercial Residential Water Supply(shared) -GROUT :. :: ->:. .:-., .:.•.:
Irri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft.
bentonite poured
JA
onitoring Recovery ft. ft.
ction Well:
� ft ft
uifer Recharge E-1 Groundwater Remediation
::19:SAND/GRAVEL-PACK if a 'licabie
'Aquifer Storage and Recovery Barrier FROM TO MATFRrnr. EMPLACEMENT METHOD
uifer Test Storrowater Drainage ftperimental Technology DSubsidence Control ft ft
othermal(Closed Loop) Tracers3'eetsaf recess -''othermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sofl/rock type,grain size,etc.)
Q �I� Q ft O ftUj
4.Date Well(s)Col;tpleted:N-1Y_;P1 Well ID# Grp ft gs ft.
Sa.Well Location: \ /�/� fL .60 ft. G �s�•
Gw�-�r �y1IC)QJ's GDi� ft 0() ft /mil
Facility/Owner
/NaameL. Facility M#(ifapplicable) M ft
Physical Address,City,and Zip ft ft.
�eJ �l6yS- !4•. d8 z1:xMARxs= -
. ..v.... r ,�. ......... .:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifw�ell�field,one lat/long1is sufficient) 22.Certification• �ti�� Jr
cY-Sy62• N ��. 8?? y W ,,.�; i Fc rjcESMV i N"
a4l �o --= rC_V , is Za zL
6.Is(are)the well(s)SPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 8No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well const•ucton information ondexplain the natut•e 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 land surface: 3 O V ( )
For multiple wells list all depths tf different(example-3(a�200'muf 2(a3100j 24a. For All Wells: Submit this fdtm within 30 day5 of completion of well
construction to the following:
10.Static water level below top of casing: �� 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
Y 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,direct push,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) . 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 type: Amount: 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016