GW1-2022-03784_Well Construction - GW1_20220404

WELL UU.y6•1.•HUCTIONRECORD (GW 1) For lnternalUseOnly:
1.Well Contractor Information: i
4tce. C�q��
•14:.We1TER ZONES:', r;
Well Contractor Name FROM TO DESCRIPTION -
Gl�s'G _ S ft aic ft
ft ft
NC Well Contractor Certification Number
l 15.OU•ERRASING,(foc multi-6isea"wells)O#2 mma(if a-umime)'
Morgan Well&Pump, Inc. = FROM TO' DIAMETERi THICIA`IEsS MATERIAL
Company Name +1 ft' ft- 61/81 1 'In, sdf21 pvc
lo Qd 16:1NNER CAMNG OR•TOBING'k eotherrmal cIo-sed-rod' ''
2.Well Construction Permit#: (a FROM TO I DIAMETER I THICENFSS MATERIAL
List all applicable well constructionperraft'(i.e.UIC,Cowily,State,Ymiance,etc.)- K• ft in.
3.Well Use(check well use): ft. ft. in
17.-SCREEN'•:-::
Water Supply Well: FROM TO DrAMETE :-SLOT SIZE YTffiCKMS MATERIAL.
_J Agricultural DMunicipal/Public ft ft
J Geothermal(Heating/Cooling Supply) 01 Residential Water Supply(single) ft ft in.
I Industrial/Commercial Residential Water Supply(shared) :18:GROUT::.
Irrigation FROM TO MATERIAL EMPL.4CEMENTMETHOD&_rMOUNT
Non-Wafer Supply Well: o ft 20 ft bentonfte• poured
`•Monitoring DRecovery ft. ft
Injection Well: ft ft
_J Aquifer Recharge 'n Groundwater Remediation r.
Aquifer Storage and Recovery Salmi Bamer -19:SAND/GRAVEL
q g ry ty FROM TO MATERIAL Fr4IPLACEMENT METHOD
Aquifer Test. []Stormwater Drainage ft ft.
1 Experimental Technology QlSubsidence Control ft ft
J Geothermal(Closed Loop) Tracer :20..TRU-=gG.DOG'(attiiEzi dditionil sheets if Fi cegs-7{; :•:'=i.
1 Geothermal(Heating/Cooliag Return) �Other(explain under#21 Rergarlcs) FROM TO DESCRIPTION color,hardness,soil/rock type grain s ze etc)
ft ft, tzeJ
,
4.Date Well(s)Completed: I -� Well ID# ft t> ft.
5a.Well Location: J ffi ft.
5gn�oS Pefe2 arse fe2 qv ft a ft
Facility/Owner Name }�/ Facility M#(if applicable) /b ft L V ft
-1 JJ 1 z"`7 U V 1. Sc 1,-s b /y ft ft
. � ft. ft
MPh - Address,City,and Zip Z2: •J;
County .Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
N W
�0 ,Sri qSq R;,.4 2022 -
a
6.Is(are)the well(s) 'ermanent or ©ITemporary :gnature of Certified Well Contractor WF l
By ia
slgning this form,7 hereby certify were)constructed in accordance
7.Is this a repair to an existing well: rJYes or WTo with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
Ifibis is a repair;fill out known well construction idformation and ex
plain the nature ofthe 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 defails or well
construction,only 1 GW-1 is needed. Indicate TOTAL NU,MBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths 1fdifferent(erample-3@200'and 2Q100D construction to the following
10.Static water Ievel below top of casing: (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe 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: c 0"r 9 .
construction to the following: I
(i.e.auger,rot ary,cable,directpush,etc.)
Division of Water Resources,Und'rground Injection Control Program,
FOR WATER SUPPLY WLLS ONLY: 1636 Mail Service Center,!Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test ail pressure 24c.For Water SuDDly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this foam within 30 days of
13b.Disinfection type: ✓��'JrvV Amount: �J 6Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised2-22-2016
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