GW1-2022-03126_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
:. ..
C4�r,5 O taa v., '14:.WATER ZONES;'. - '.•: : .. .... ....-:.:; ..
Well Contractor Name FROM TO I DESCRIPTION r
35�7 a /` fL ft ,
/z T J ft ��� ft.
NC Well Contractor Certification Numbet
15;OIITER:GASING,for mnlli=rased webs)O)2 LIlYE1t if a'licahle'
Morgan Well&Pump, Inc. FROM TO I DIAMETER I THICKNESS MATT2RTdr.
+1 ft OR5, ft 61181 in' sd21 pvc
Company Name
���I- 03 a 16:7NNER CASING OR•TIIB]NG.' eothermal closed lot` : '':' t::
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'r e.07C,Countg Stale,Ymiance,etc.)- ft, ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17:SCREEN',:-.. `_ . .`�: °_•..::.:.:::.:. ;,.: ,::.;:• :. ..:: .-:
FROM TO DIAMETER. SLOT SIZE THICKNESS IYIATERiAL .
Agricultural CiMunicipal/Public ft ft. in.
Geothermal(Heatiag/Cooling Supply) R<widential Water Supply(single) ft ft. in.
I Industrial/Commercial E3Residential Water Supply(shared) _
::18:GROUT•: _., .,_
S Irrigation FROM TO MATERIAL M EMPLACEMENT METHOD&AMOUNT
1.Non-Water Supply Well: 0 ' ft 20 ft bentonite poured
'•Monitoring M-0--ry ft. ft
Injection Well: ft ft
J Aquifer Recharge Groundwater Remediation
A urfer Stora a and Recove �;�,Salim Barrier ;:19:SAND/GRAVEL'PACK if
9 g ry ty FROM TO • MATERIAL I EMPLACEMENT METHOD
1 Aquifer Test [3Stormwater Drainage ft ft
PExperimental Technology QlSubsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.tiR1LLING.LOG'(atticli=additidnal sheets f i ecess-')
I '
I Geothermal(Headrig/Cooling Return) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solYrock type in size,etc)
_ _ _ _ �a Red C'
4.Date Wel1(S)Completed: Well ID# f. ft' ? ft S
5a.Well Location``:'' 71� ft Zyd ft �� mia 14
Y+ f70r -o ft / ft
Facility/Owner Name Facility ID#(if applicable) ft ft
3W N1i 115 CrG rkAA& ft ft
Physical Address,City,and Zip QQ ft ft _ _..__ .' 0^ I )
L/MLO�K -
IS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �
(if well field,one]at/long is sufficient) �y.�pp�y�.
22.CS atio tO:TLiiY #11 Rtr�FI`mx,`u"O U)\q I
5.5762 N -Sl. //3 VS"
6.Is(are)the well(s) Permanent or ;
Signature of ettifie ell Contractor Date
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 o with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Consavction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the natw•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-I 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: (ft) 24a. For All Wells: Submit this form within 30 day8 of completion of well
For multiple wells list all depths if different(example-.3Qa 200'and 2@a 10oq construction to the following:
10.Static water level below top of casing: 0 (ft) 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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotAr L�
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.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 2769 9-1 63 6
13a.Yield(gpm) I Method of test: air pressure 24c.For Water SunDly&Iniection 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: &MU14J Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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