GW1-2022-03128_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only
1.Well Contractor Information:
,�f15
•14:.DyATER ZONES:'. ''-: :•. _
Well Contractor Name - FROM TO DESCRIPTION Y
ft lSr ft-
NC Well Contractor Certification Number ft. ft.
15:0Q7ER:QAS1NG,(focmniti4'rasedwelLs)O'Rlm'ESi(ifa'licable'
Morgan Well&Pump, Inc. FROM TO' DIAMETER TffiCKNESS MATERIAL
Company Name +1 ft L ft 6 1/6/ in• sdi21 pvc
��''l)jjg re�j ][Ct MR CASING OR-TUBING."•eothei'ma1'clo'sbd rod'
2.Well Construction Permit#:iE14 /' C?salf FROM To DIAMETER THICKNESS `..•MATERIAL
List all applicable well constructionpermus(i.e.UIC,County,State,variance,etc.)- ft• ft in.
3.Well Use(check well use): ft ft in
Water Supply Well: 17,'SCREEN', _
Agricultural Mom TO' : :`- DIAMETER i^SLOT SrZE THICKNESS, "RMATERIAL .
0Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) mdential Water Supply(Single-)
pp y(sin a ft ft in.
Industrial/Commercial DResidential Water Supply(shared) .18.GROUT
i Init
Non-n-Waatee FROM TO MATERIAL EMPLACEMENT METHOD&AMOl7NT
r Supply Well: 0 ft 20 ft bentanite poured
Monitoring Recovely ft. ft.
Injection Well:
I Aquifer Recharge. [J Groundwater Remediation
ft ft.
Aquifer Storage and Recovery :.19S&ND/GRAVEL-PAKa'-liable t Barrier .-.:,'-'-. +:"`:- :: . ..•'; _
FROM TO • I "EMPLACEMENT METHOD •.
Aquifer Test DStormwater Drainage ft ft
I Experimental TechnologyoJ'Subsidence Control ft ft.
i Geothermal(Closed Loop) OTracerDRILLING.L'OG-(,;i 'iE-idditioti'sl s7ieetsafiiCeess_'l".;, `•'.=s
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) ft.
TO DESCRIPTION(eolo,hardness soiUrock rain size,et
ft ft.
4.Date Well(s)Completed: Z-2-1—Z2— Well ID# 't�r. ft ft
a
Sa.Well Location: ft gS ft.
00
Facility/owner Name
�„ i �4Facility ID#(ifapplicab)e) ft
ft ft
Physical Address,City,and Zip ft ft
MAR 0
County Parcel Identification No.(PAN) M• rn r .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C lion:
SD N
6.Is(are)the we `Permanent or Oi Temporary Signs. ofCertifi a ntractor Date
By signing this form,I hereby certify that the jwell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: .QYes or P< with 15A NCAC 02C.0100 or 15.4 NCAC 02C,0200 Well Construction Standmds and that a
Ifthis is a repair,ftll out known well construction biformation and explain the nature ofthe copy ofthii 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 bf wells construction details. You may also attach additional pages if necessary.
drilled:_ 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D (fL) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100)
construction to the following: '
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino'use"+" e
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: r 0. Y(�� above, also submit one copy of this form within 30 days of completion of well
�(i.e.auger,rotary,cable,da construction to the following:
ectpush,etc.) i -
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield m air pressure
(gp ) © Method of test 24c.For Water SunDly&Injection Wells: In addition to sending the form to
f�! the address(es) 'above, also submit one copy of this form within 30 days of.
13b.Disinfection type:W 4t Amount. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmenml Quality-Division of Water Resources Revised 2-22-2016