GW1-2022-03802_Well Construction - GW1_20220404

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I I
1.WeD Co tractor Information:
14:.WATER ZONES
Well Contr or ame FROM TO DESCRIPTION
2z� ft ft
ft ft f
NC Well Contractor Certification Number d '
t 15:ouxKeAsn,�rGdfoi•xhiatTii sedwebs)O tT--M1W-R(if Iicable.; ".::'•.'._
Morgan UI/efl.&Pump, Inc. FROM TO' DIAMETER THICENESS FMATERIAL
Coro an Name +1 ft' ft. 81/81 in' sdr21 pvc
P Y I INNER C Olt•TQBAVG
2.Well Construction Permit: �yl FROM TO DrAMETER TBICENESS MATERLu,
list all applicable well construction permits*rLe•UIC,County,State,Parlance,etc.), ft• ft. in
3.Well Use(check well use): ft ft in.
Water Supply Well: -
FROM TO DIAMETER•:� SLOT SIZE -THICKNESS MATERIAL.
pAgricultural r1iMunicipaUPublic ft ft.
Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft in.l
ludustrial/Comniercial Residential Water Supply(shared)
::18:GROUL:
f Ilil atiOn FROM TO MATERIAL Y J EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft, 20 ft• bentonite i, poured
Monitoring Recovery ft. ft
Injection WeII: '
ft ft.
Aquifer Recharge DJ GroundwaterRemediation r
Aquifer Storage and Recovery Salmi Barrier
`�:S<]PID/GRAVEL PACK ff a"lica6le ':.:;._ :: :..,._'::•. •..i. _:.: ..'
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0stormwater Drainage ft iL
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRILLIIIG.LOG'(attacli'additional slieersif iiecess""j`�' i'•=s
Geothermal(Fieating/CooIing Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(molar,hardness,sail/rock type main s ze efe)
It l5 ft 1
4.Date Well(s)Completed: Gli Well IN ft 3I ft. L7
Well Loc lion: 3 ft D ft
iron�t'���e�S ft ab ft-
Facility/Owner Name J Facility M4(if applicable) ft ft
A AG . ft ft
ryZhys:calAddress,City,and Zip f + 2, Q_ ft ft
l�►J�V.w ��` ���, :'216�rFnreRuc� _i%
County Parcel Identification No.(PIN) I • ¢_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ n V
(if well field,one lat/long is sufficient) 22.Certification: APR 7 4 2027•
-N ado • W
6.Is(are)the well(s)&Permanent or OTemporary. =..V, 1h1sjbrm,j
Certified Well Contractor V �N1IMI Pa`�0CEI' -a 3:KIT,
hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I �Yes or IWNo with 15ANCAC 02C.0100 or7SANCAC 02C.0200 Well Construction Standards and that a
Ffthis is a repair,fill out(mown well construction information and explain the nature ofthe copy ofthis record has beenprovided to She'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 NUMIMER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ t1 SUBIYIITTAL INSTRUCTIONS
VtD
9.Total well depth below land surface: (ft•) 24a. For All)Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erarnple-3@200'and 2Qa 100) construction to the following:
10.Static water level 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.)iorehoIe diameter: 6 (in.) 24b.For Infection 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� A L� construction to the following:
(i.e.auger,rotary,cable,directpusb,etc.)
Division of Water Resources,Underground Injection Control Program,
LFORATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ld(gpm) 20 Method of test air pressure 24c.For Water Sunuly&IniectionlWells: In addition to sending the form to
the address(es).'above, also submit one copy of this•form within 30 days of
infection typ ( _ Amount: Z completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Deportment of Environmental Quality-Division of Water Resources Revised 2 22 2016