GW1-2022-03163_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD (G:W-I) For Intemal Use Only:
I.W C ntractor ormation:
14:.WA.TER ZONES
Well Contactor a FROM TO DESCRIPTION
ft ft. I
'•f tea• ft ft Il
N'Meh Contractor Certification Number
'15:OUT'ER:CASING,(foc mniti�ased wells OI2LZNER(if a'linable' :�:i'.�.:i'-.`.=
Morgan Well&Pump, Inc, l FROM TO" DIAMETER THICKNESS MATERIA3
Company Name ,
+1 ft. M5 ft' 6 1/8/1. in' sd21 pvc
2 �f_ 16.INNER CASING OR-T[JBING.' eotlierma7 closed-lod'
2.Well Construction Permit#: I FROM TO I DIAMETER I TffiCKNESs. MATERLSL
List all applicable well co»structfon permits'fl.e.07 ,Comnv State,Ymiance,etc)• ft ft in.
3.Well Use(check well use): ft ft. in.
i
ter Supply Well: I-.SCREEN'.
FROM TO DIAMETER SLOT SIZE •TASCKNFSS MATERIAL.
gricultural []Municipa]/Public ft. ft. in.eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ftdustrial/Commercial OResidential Water Supply(shared) __................:. ..:.:... .
rGeother.3nal
onOGMROUT.TO
_ rFurer. y" :r :. ..:•.: '.;:•.: ,.•-::
EMPLACEMENT METHOD&AMOUNT
ter Supply Well: 0 ft. 20 ft
bentonite poured
ring Recovery ft. ft
Well:
ft ft
Aquifer Recharge E3 Groundwater Remediation
•:19:SAND/GRAVEL'PA.CK if a'livable
r Storage and Recovery Salinity Barrier FROM TO MATERIAL" EMPLACEMENT METHOD
r Test QlStormwater Drainage ft ft.
ental Technology QlSubsidence Control ft ft
rmal(Closed Loop) Tracer :20.DRIILING.L'OG'(attscli'sddition'alsheefsafneces's--rmal(Iieating/CooIing Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hard ess,s iUrock ty e in s ze etc)
O ft 2_0 ft
n 1: 22
4.Date Wells)Completed:2 Well 1D# ft '.34� ft.
�
JJ
Sa Well Location: ft.
ft
ac'`ty/Owner Name �Lf Facility ID#(ifapplicable) M ft
9 c%-5 �v,b�r��c l2d ( 1b �� �1c.2W1 ft ft F? E II IP )"
teal Address,City,and Zip 1 ft ft
W e.Y1 523 1 `1 21:ItEMAuuc= - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: -
(rfwell field,one lat/lona is sufficient) %.T L','fro"y�it.J. ri i;,CJ�,•:U t
22.Certification:
35.5�7�1 N - go.33 S W Z t zy
6.Is(are)the well(s)*Permanent or OTemporary 6h4C
a ofCertifie Well Contractor Date
i 'g this form,I hereby certifythat the wells)was(were)constructed in accordance
7.Is this a repair to an existingwell: []Yes orlkNo ISA NC 02C.0I00 ar)SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well consu•uction information and explain the nature ofthe copy ofthic 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 NUNMER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:2oa (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifferent(example-3 a 00'and 2@100� construction to the following:
10.Static water level below top of casing: D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) I
24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(Le.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 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniectionll 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 tyA 11`fJn*V1fi Amount: 7 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