GW1-2022-03172_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W ntractor Info oration:
14:.WA.TER ZONFS -
Well Con t •Name FROM TO DESCRIPTION
ft ft
ft ft '
NC Well Contractor Certification Number 15:OUTER CASING,(foc multi-rased•webs OIt LIIq$R if a-'linable' :::''.:
Morgan Well&Pump, Inc. FROM TO" I DIAMETER I THICKNESS MATERIAL
+1 ft. fr 6 1/8/ P t in' sd2l pvc
Company Name ., "
2����jj �4/ 16."INNER CASING OR•TOBING.•"eothermal closed-lod' r.
2.Well Construction Permit#:�L�L1 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction pearits'r.e.WC,Comrtv,State,Pb iance,etc), ft ft in.
3.Well Use(check well use): ft fr, in.
Water Supply Well: 11 SCREEN•.:. ; :`::. . _:. .:,...•.. : '• =
FROM TO DIAMETER SLOT SIZE THiCKNESSr MATERIAL .
1 Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I Industrial/Commercial Residential Water Supply(shared)
i hI'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
'•Monitoring Recovery ft. ft.
Injection Well: ft ft
-J Aquifer Recharge Groundwater Remediation r
•:19: AND/GR SAVEL'PACK if a'licatile :-
Aquifer Storage and Recovery ©II Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRILLING.I OG'(attacli'sdditioa'sl slieetsifnecess _
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
4.Date Well(s)Completed: .b 2Z, Well ID# Zv ft r
Sa.Well Location: 4445 ft ftSa
'
^�� ft. l ft
Facility/Ow er Name r+� ` 1N1�1 Facility M#(if applicable)` 15 ft `0 ft
S, L
515 Vv�lv,d+'1.1. K., \ 6p 1`w/ a�v�Ti ft ft
Ph s�ii all AAdddress,City,and Zip ftft.
a/�l J+� g,, A m 21:I2EMARBS= - `-r' _
r (�
V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in dea ees/minutes/seconds or decimal degrees:
dwell field,one lat/long is sufficient r �'
22.Certification tOt, vLJo,iC 1
35 7(�2 'N g0(wD v W 'L
6.Is(are)the well(s)*Permanent or QIJ Temporary Signah ofylified Well ctor Date
By lung trm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or nI No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standmds and that a
If this is a repair fill out known well construction information and explain the nature of the 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-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: U0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: 1315 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,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
above, also submit one copy of this!form within 30 days of completion of well
12.Well construction method: r Q" LA 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&IniectionI 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 { 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