GW1-2022-03109_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only.
1.Well Contractor Information:
14:.WATERZONES;'.
Well Contractor Name FROM TO I DESCWYT10N
ft ft.
NC Well Contractor Certification Number
15;OUTER;CASING,foc multi=rased wells)OR M?ER
M (if a licable'
Morgan Well &Pump, Inc. FRO TO' DIAMETER THICM ESS I MATERIAL
Company Name +1 ft ft 6118/ ! in. sd21 pvc
p y L 1ti:INNER C' G OR TUBING. 'eothe."rmalclo'sed-lod'
2.Well Construction Permit#: `r I O S1S� FROM TO DIAMETER TEaCIINESS I MATERIAL
List all applicable well constructionpermits'(Le.WC,County,State,Variance,etc.)- ft. ft ! in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17."SCREEN'.
VROM TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL .
J Agricultural QMunicipal/Public ft M in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft
lndustrial/Commercial J Residential Water Supply(shared) l GROUT."..
'In i ation FROM TO I MATERIAL EMPLACEMENT METHOD&4MOIINT
Non-Water Supply Well: 0 ft 20 ft.
bentonite poured
Monitoring Recovery ft ft
Injection Well:
J Aquifer Recharge QGroundwater Remediation ft ft
Aquifer Storage and Recovery Salmi Barrier >19:SAND/GRAVEL PACK>f a'Ilcablb:
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
i Experimental Technology QI Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRIIS NG.LOG'(itti6l dditidi0 s7ieed.if iieceg's"-j':s'�'•:'=s '
11 Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardneu,soiUrock ty e,grain size,ere.,
ft 14 ft
4.Date Well(s)Completed: LIIo-2L Well ID# L1. ft rift.
5 Well Location: vft (-ft
b
Q k'ul wM ;m / ft ft Yl
Facility/OOwner�Name Facility ID4(if applicable) ft ft
TO c 6-egt/ t ft ft
Physi Address,City,and Zip ft ft
VI`nG0 16161-11 2I:Rl7MARKC - :. ;31i.
County Parcel Identification No.(PIN) g 9�
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: 2022
(if w ll field o
qla ong is sufficient) 22.Certification
ROT W1
6.Is(are)the well(s)lWermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlijy that the well(s) was(were)'con#eructed in accordance
7.Is this a repair to an existing well: E'Yes or No with IAA NCAC 02C.0100 or IAA NCAC 02C.0200 Well Conshuction Standards and that a
If this is a -epan•,fill out known well conshuction itiforman.on nd exp th lain e notm•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.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CIO ft
( ) 24a. For All Wells: Submit this form within 30 day§ of completion of well
For multiple wells list all depths if different(example- @200'and 2@100) construction to the following.
10.Static water level below top of casing: O (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: D I(LI above also submit one copy of this form within 30 days of completion of well
(ie,auger,rotary,cable,dvectpush construction to the following:
,etc.) t
Division of Water Resources,Underground Injection Control Program,
L13b.
ATER SUPPLY'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ld(gpm) l� - Method of test: air pressure 24c.For Water Suunly&Iniection Wells: In addition to sending the form to
/� the address(es) 'above, also submit one copy of this form within 30 days of
infection type: rrc,,J 01 Amount: b v 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 f Revised 2-22 2016