GW1-2022-03105_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
I.Well Contractor Information:
f
—i J 14:.WATER ZONES - : ,,
,'4,t: •" Well Co ctorName FROM TO DESCRIPTION c
ft..
ft ft
NC Well Contactor Certification Number
15;OUTER:CASIl�l�,for multi=rased*aJs)OR LIlYER(ifa'livable'
Morgan Well&Pump, Inc. l FROM T DIAMETER THICKNESS I MATERIAL
Company Name � +t f' ft 61/s/ 1 m• sdr2l pvc
1' 1 I ? J�1 I6;INNER CASING OR-TfJBING. eottierraal c1o'sed lod'
2.Well Construction Permit#:11.. l.Ji� FROM. I To I DrAMETER. _THICKNESS •MATE ZIAL
List all applicable well constrvctionpermits r.e.WC,Catmll;State,Variance,etc)• ft fL in.
3.Well Use(check well use): _ ft ft in.
UWaterupply Well: DIAMETER! .SLOT SIZF THICKNESS MAltural MMuaicipaUPublic, ft ft in.
rmal(Heating/Cooling Supply) ©Ii Residential Water Supply(single) ft ft inial/Commercial )IResidential Water Supply(shared) -
rExperimental
on ::YB:GROUT..*•: -•:. .: •'�:.•... ;v - :.,;.., �.;�::. •�'; ::.:,:-_•-`:.
FROM TO .,MA'r'F'RT 2 - - EMPLACEMF.NTMETHOD&4MOUNT
ater Supply Well: 0 ft 20 ft
bentonite' poured
Monitoring Recovery ft ft
n Well:
Aquifer Recharge ft ft.
g �J Groundwater Remediationr Sto_ a and Recov !.19:SAND/GRAVEL PACKg ery SalinityBarrier FROMTO MATERTAT• EMPLACEMENT METHOD
r Test Ostormwater Drainage ft ffimental Technology [3Subsidence Control ft ft
rmal(ClosedLoop) Tracer :20.-RILLL�'G.IOG'(kttiEYidditidn-slslieetsifaecess""'':t'rmal(Iieating/CooIiag Return) J Other(explain under#21 Remarks) FROM TO DESCRIP ION(color,hardness,soillrock type,grain size,etc-
/ ft ft
y �/�(,tr t
4.Date Well(s)Completed �y ID# ft O ft
Sa.Well Location:' < fr-
ft L ft 1 ,
Facility/Onerame -- Facility ID#(ifappIli(c aable) ft ft
ft � ft.
z alin Ar n r'
rt
Physical Address,City,and Zip ft ftWAR 0
:.
County Parcel Identification No.(PIN)
��C�u �Q�►ef VIA i0
Sb.La e and ongitu a in degrees tes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tioII / e5;T[/�Y11 t�r� r4:1'2 *i
16a
,��(( 17311 w -� Z / �� zz
6.Is(are)the well(s)l permanent or Temporary Signature of Cert ed Well Contractor Date/
7T'�� 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: QYes or IJ No with 154 NC4C 02C.0100 or 15A NCAC'02C.0200 Well Construction Standmds and that a
If this is a repair fill out(mown well construction information and explain the nature ofthe copy ofthis record has beenprovided 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: !. r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3@200'and 2@100q 24a. For All Wells: Submit this form within 30 days of completion of well
r construction to the following:
10.Static water level below top of casing: ( _) (ft) Division of Water Resources,Information Processing Unit,Ijwater level is above casir:g,use"+" e �
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method �0 r L above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpush,etc.) construction to the following:
EWATERUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water Sunuly&Injection�Wells: In addition to sending the form to
s` the address(es) 'above, also submit one copy of this form within 30 days of
type: Amount: �0 2 completion of well construction to the county health department of the county
where constructed. i
!
Form GW-1 North Carolina Departinent of Environmental Quality-Division of Water Resources Revised 2 22 2016