GW1-2022-03801_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well i ntracttor Information:
14:.WATERZONES•:'.
Well Con a torName FROM TO DESCRIPTION
1�C/� A U ft. a It
J VV ft ` ft
NC Well Contractor Certification Number '15:0=-R:CMiNG•,(fo"r multi=,a ea welk)oR LmgR(if a'livable)'1
Morgan Well&Pump, Inc. = FROM TO' I DIAMETER THICKNESS MATERIAL
Company Name
+t ft- ft- 1 61/B/ ! in. sd121 pvc
1P n / // /J /] t OIL ��\ 16:IlVNER C 4SING OR•T[1BING."eothe'r'�al closed lao' ='�' :;
2.Well Construction Permit#/: ``�/�/(�, ocL ` a FROM TO DIAMETER TMCI44EsS MATEICI L
List all applicable well constuction permits'rL e.VIC,County,Stale,Variance,etc.)- ft % in.
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.SCREEN',:.:.: `_:. .'�.;'•.:•_.:.:.::is ;: ::._,.:'�::.. .:::° .:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL.
._?Agricultural nMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft
I Iudustrial/Commercial DResidential Water Supply(shared) .18:GROUT-.'-..
[Geothermal
tion FROM TO MATERIAL EMPLACEMENT METHOD&.4MOUNT
ater Supply Well: 0 ft 20 ft. bentanite poured
toring Recovery ft. ft.
on Well:
ft ft
fer Recharge Oi GroundwaterRemediation r
•.19:SAND/GRAVEL P9 CK if a 'livable
er Storage and Recovery DSadnity Barrier FROM TO MATERL41 EMPLACEMENT METHOD '
er Test DStormwater Drainage• ftimental Technology Subsidence Control ft ftermal(ClosedLoop) Tracer :20.DRMUING.LOG'(aL adE-additidrislslieetsjfiie&gh kj:i==t•i'=.i :'-
ermal(Heating Coolie Return) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc)
�/ 22g ) _ Other(explain under#21 Remarks) ft ft TLej
4.Date Well(s)Completed:✓-2 Well ID# / ft t3 ft LJ^ r.oL
52. ell Location 66
�C'l�b t'C. VG�Uprae� / ft ft
Facilityy//Ow erName 'I Facility ID#(iiffapplicable) ` ft ft
S�/ldd ft ft.
Physical Address,City,and Zip — ft ft-
County Parcel Identification No.(PIN) 02Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/long is sufficient) C� 22.Certification a°s~ t^��lL
�•1/0 7o -N 0'0'� / ^�i1�" fS J� "iiv�t�j l'1
6.Is(are)the wells) Permanent or MTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or , 1 No with 15A NCAC 02C.0100 or 15A NCAC 02C-.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature ofthe copy ofthis record has beets 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.TotaI well depth below Iand surface: 3 Q V (ft
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i'different(example-3 a@200'and 2QaII100) construction to the fallowing:
10.Static water level below to of casin V
•Ifwater level is above casino use use"p" g (ft.) Division of Water Resources,Information Processing Unit,
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
�-• .9—A above;also submit one copy of this form within 30 days of completion of well
12.Well construction method: l I. `mot r L� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centier,Raleigh,NC 27699-1636
13a.Yield(gpm) 16' /:L Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit oriel copy of this form within 30 days of
13b.Disinfection type: J f4oJ 6✓ Amount: I d Z completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016