GW1-2022-03162_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W ontractor I motion:
14:.WATER ZONES
Well Contract rName FROM TO DESCIUTION
ft ft.
t
ft ft
NC Well Contractor Certification Number
15.OUTER;CASING,(foc multi-cased•wells)OR M ER(if'a-'livable)' .:`:.; •.
Morgan Well &Pump, Inc. FROM TO' DIAMETER TmcIf`ms MATERIAL
Company Name +1 fr �j 61/al k in' I d21 pvc
16.INNER CASING OR TIIBIIVG:' eotheimal closed lode
2.Well Construction Permit#: FROM To I DIAMETER T THICKNESS MATERIAL
List all applicable well construction permits'(i e.WC,County,State,Ymiance,etc.)- ft ft in.
3.Well Use(check well use): ft fr. in.
-SCREEN',Water Supply Well: 17- -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
Agricultural QMunicipal/Public ft. ft_
]Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. - ft in
I Industrial/Commercial DResidential Water Supply(shared)
{hri ation GROUT-. • .:. .: '-:.':.'.'.�; --.:. .;•:: .�;L, : ._':
FROM TO MATERU EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite' poured
Monitoring Recovery ft.
ft.
Injection Well:
� ft ft
_I Aquifer Recharge rJj Groundwater Remediation
:19.SAND/GRAVEL-PACK if a'licatili
Aquifer Storage and Recovery O Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater•Drainage ft ft
Experimental Technology Subsidence Control ft ft-
Geothermal
(Closed Loop) [ITracel' :20.DRILLING.LOG'(attacli-iddition'ilslketsifiiecessti"l':t. '
Geothermal eating Coolie Return) FROM TO DESCRIPTION(color,hardness,sollirock type,grain size,etc.)
(H � g ) �Other(explain under#21 Remarks) O ft O ft.
4.Date Well(s)Completed Well ID# 2P ft
5 , ell Location: ft /s it.
. f� LL
ft lay ft
Facility/ weer Name Facility ID#(if applicable) t •+ ft >ft
ft ft j
ysi�ca�l�A/}ddress,City,and Zip ft it-
County Parcel Identification (PIN) MAH U 12.027.::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
S
qbo Qr� / 22.Certification: 41,i.28 U W -N - OV.�Oa�O W ZAo Zy
6.Is(are)the wells)J§Permanent or OTemporary re Cer'a ellContractor Date
ng this form,I hereby cerirfy that'the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or NNo with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repan;fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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:. .W (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100D construction to the following:
�45 (ft)
10.Static water level below top of casing: . Division of Water Resources,Information Processing Unit,
IVwater level is above casino use"+^ 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: O Y LI above,also submit'one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following: j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) air pressure Method of test: 24c.For Water Sunuly&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 typ WVC* Amount: d j/ 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 �' Revised 2 22-2016
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