GW1-2022-03804_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
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1.Well Contractor Information:.
-14:.WATER ZONES•c'.
Well Contract •Name FROM I TO I DESCRiPT1oN
� � ft ft
i
ft ft
NC Well Contractor Certification Number
15:OIITER,(?ASING,(i&rhult!='a ed weDs)09 BRJER(ira"'liable-t;
Morgan Well&Pump, Inc. FROM TO' DIAMETER! THICIfS I MATERIAL
+1 Company Name ft' I VC5 ft- 1 61/8/ f In. 1 sd21 1 pvc
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�j`r / I INNER CASING OR2-TUBING:' d6fl eimal ci6-sed-lod'
2.Well Construction Permit#: s(,r7(Q 1� ' FROM TO DIAMETER macmms I MATERIAL
List all applicable well constructionpermits'ri.e.EUC,County,State,Variance,eta)- ft. ft. I in.
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3.Well Use(check well use): ft• in.
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THIC&1VE89 MATERIAL.
Agricultural r'jjMunicipal/Public ft ft in.i
i Geothermal(Heating/Ccoling Supply) DResidential Water Supply(single) ft. , ,ft
IndusiriaUCommercial DResidential Water Supply(shared) >'1S..GROUT•::." "
E hii ation FROM TO -MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ' ft. 20 ft bentonite poured
'Monitoring DRecov,,iy ft ft
Inje We]I: ft ft
Aquiferction Recharge j3GroundwaterRemediation r.
Aquifer Storage andlmi Barrier �'SAID/GRAVEL PACK if a"liable
Recovery Sa _ ::.:._ •:•. •..i: ' i'
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage- ft ft.
r_TkExperimental Technology (Subsidence Control ft ft
RGeothermal(Closed Loop) 13Tracer :20.DRMIING.L'OG'(attacli additidn'al s eetsifrieces's "j::{: :•'r -_
Geothermal(Heating/Cooling Return) r-ij Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,soil/rock type,grain size,etc.)
C ft C>S ft
4.Date Well(s)Completed: Well M#
-ft. S ft
55a]�Well Location- 5 5 ft
' 1 •� 11 15 ft
Faciliitty/OwnerrNaame �Facility
,I�N(ilfapplicable) S ft 0 ft
�C.a rN ���IIUw
Ph s'at Address,City,and Zip ft ft -u
a
bib _ ;�
71..S(
County Parcel Identification No.(PIN) APR —j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ..
(if well field,one lat/long is sufficient) is 2 4n
2.C rtit3ration: , �7�.:'r'�a;+31v�14;i'
��J•�J�D3� NiR '�)`i3C�Jl=riCi '
6.Is(are)the well(s)*Permanent or QlTemporary Sig 4"hisfarm,
Certified Well Contractor Da e
�,{ io ri I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: CJtYes or *No th ISA NCAC 02C.0.700 or 111 NCAC 0?C:0200 Me11 Construction Standards and that a
Ifthis is a r epai-,fill out known well construction information and explain the natw•e ofthe copy ofthis record has been provided to the well owner.
repair under 921 r•ernarkv section or on the back of this form. i
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: II SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dier ent(example-33@200'and 2@100) construction to the following:
10.Static water level below top of casing: J� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.} 24b.For Injection Wells: In addition'to"sending the form to the address in 24a
1 2.Well construction method: f-oY
f above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,directpusb,etc.) i •,
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Silpply&Injection 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 type_ Amount:ZZ 6T1 completion of well construction to the county health department of the county
where constructed.
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Revised 2-22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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