GW1-2022-03169_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only:
1.Well Contractor Information:
'IGtC Cep �cx, e :- ... ..� ..
� •14:.WATER ZONES;'. ,-
Well Co c e FROM TO ` DESCRIPTION
c� - 6 b ft ZV ` ft
ft ft i
NC Well Contactor Certification Number I
15:OIIZEReASING,(fric multi=fasedweDs)O_L7IQEIt if"licahle'
Morgan Well &Pump, Inc. FROM TO' DTenrarFR ITMaaWS I MATERIAL
Company Name +1 ft CZ ft 61/8/ i in sd21 pvc
` �/' � 16:7NNER CASING OR•TIIBING.'•eotliermalcla'sed-lod' "='•�' :•;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consbuction permits'ri.e.LUC,Comity,State,Variance,eta)- ft• ft in.
3.Well Use(check well use): ft ft. in.
iWater Supply Well: 17.-SCREEN'. -
MOM TO DIAMETER SLOT SIZE TAICKNFss IYIATERIAL .
gricultural �Municipal/Public fL ft in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ftftdustrial/Commercial [3Residential Water Supply(shared) .iYBr GROUT:?
i hTi ation FROM TO MATERIAL EMPLACEMENT METHOD P,AMOUNT
Non-Water Supply Well: a ft 20 ft.
bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
ft ft
__ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK if k •lieable " r' `: '
`Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage- ft.
I Experimental Technology Subsidence Control ft
'Geothermal(Closed Loop) [31racer LLO-i�2Lt�-LOG'(�k�il��dditii;ziia sheedifi eeesss-j.,�I Geothermal(FIeating/Cooling Retum) Other(explain under#21 Remarks) DESCRIPT ON(calor,hardness,sail/rock typ in size,etc`
Uft ft. �rlr
4.Date Well(s)Completed:�� ^° Well ID# ft ft' O Lin AO,tr
Sa.Well Location: vft 16d ft t,,t.. j ( j!
On 10('T 6� 6 ft '0 ft J S
Facility/OwnerNamee Facility lD#(ifapplicable) ft Z�ft r�l
L� ./ � ft. ft vY Lok o L 6, 1= a!
— 11
Physical Address,City,and Zip ft ft. K F Z.W V�y IVA `
- -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: -
(ifw 14cld one
jlat/llo]ng�iisssufficient) �( ` a `` ;?' ,.Yf;.41
�,�� •"Y� li �1 V o. �1 1 4` 22.Certificati n• Mt^�����'- '�Yt�, e3:�� ei t ^ q
N W ��9/txry oCl- ao�a
6.Is(are)the well(s) rmanent or OTemporary Signa a of Certified Well Contractor
0Date —�
vvVVV By signing this form,I hereby cettify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r'Yes or No with 154 NCAC 02C.0100 or 15A MCA 02C.0200 Well Construction Standards and that ae
gthis is a repair,fill out!mown well cons6•uction information an explain the nature Df the copy ofthii 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 bf wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 and 2Q100�
construction to the following.
10.Static water level below top of casing: Gf� (ft-) Division of Water Resources;Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
lI.Borehole diameter: 6 (in.) 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: 1 construction to the following:
(Le.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
[FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Xield(gpm) Method of test: air pressure24c.For Water Supply&Iniection Wells: Iri addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
b.Disinfection type:Aflcinj !x,/ Amount: 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