GW1-2022-03808_Well Construction - GW1_20220404

W 1+1LL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
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— •14:WATER ZONES;'. :•: � =_L• ...r.:�:i'';.
Well Contractor Name ROM TO I DESCRIPTION '
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ft ft I '
NC Well Contractor Certification Number
15:OIITER:(?ASING,(fo"r multi-rased wells)OR Tr�R(ifa'licable)'.; ?:.::'•.
Morgan Well&Pump, Inc. I FROM I TO* I DIAMETER! I THICENFSS MATERIAL
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Company Name ft ft' 61/01 I m, sdr21 pvc
16"IIIIQERCASITT OR•TUBIlV .Veothe, 'al
2.Well Construction Permit#• 1 FROM To Dlanti TER THIClams nv,TER.TAL
List all applicable well constructionpermits'(r.e.UIC,Cow*,State,Parlance,eta)• ft ft. in.
3.Well Use(check well use): ft ft, j- in.
Water Supply Well:. 17-SCREEN',01ROM TO - - *DIAMETE I SLOT SIZE THICKNESS hIA—TAL'Agricultural 0Muaicipal/Public ftin i Geothermal(Heating/Cooling Supply) RResidential Water Supply(single)I Industrial/Commerciai Residential Water Supply(shared)IItTi ation DT::• ' ti :r••-�.,
FROM TO MATERU L EMPLACEMFNf&fTHOD&4MOTINT
Non-Water Supply Well: a zo ft bentonite- poured
'Monitoring [3Recovery ft. ft
Injection Well:
Aquifer Rechar e �—;{ ft ft i'
q g t�tCnoundwaterRemediation _
Aquifer Storage and Recovery i Salini Barrier :�:SLID/GRAVEL PACK if a "linable '. :.;:_ .: •.. ' ', ,
ty FROM TO • MATERIAL EMPLACEMENT METHOD
Aquifer Test 0stormwater Drainage ft ft
i Experimental Technology, QlSubsidence Control ft ft
Geothermal(Closed Loop) Tracer :20,DRILLING.LOG'(attacli'sddition'sl sTieets�f recess"")''{'
Geothermal(Heating/Cooling Return) 13 Other(explain under#21 Remarks) FROM TO I DESCRIPTION(color,hardness,sowrock type,grain size,etc.) '
ft ft � ,�.
4.Date Well(s)Completed: Well ID# 0 ft ft, et) t
5a.Well Location: ft 9S ft
Dlcy � LV, ft i ft
Facility/Owner Name / ID#(ifapplicable) ft ft-
Facility ft ft
Physic ddress,(CQity,and Zip G[� ft ft
- �-` ������ `� •21c'R�i.MARKC=- :r.,.- `:J- raie .it�� ._t. - =_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(if ell field,one lat``/long is sufficient) (� u 22.Certification
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6.Is(are)the well(s)UIPermanent or OTemporary Signa Certified Well Contractor Date .
By sio ring this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QI Xes or j No with 15ANCAC 02C.0100 or 15A NCAC Ok-.0200 Well Construction Standmds and that a
rjflris is a repair fill out known well construction irr ormation and co o th''
f explain the nature of the copy.l rr record has been 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
coustruction,only 1 GW-I is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ t1 SUBMITTAL INSTRUCTIONS
9.Total well !!``depth below land surface:_ a (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(�00'and 2 r0,�1 construction to the following.
10.Static water level below top of casing:. V (ft.) Division of Water Resources Information Processing.Unit,
Ifwater level is above casing,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
12,Well construction method:
� above,also submit one copy of this form within 30 days of completion of well
:(i.e.auger,rotary,cable,direct push,etc.) construction to the following: I, !
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
,l _ 1636 Mail Service Cente i,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: air pressure 24c.For Water Suuuly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fomi within 30 days of
13b.Disinfection type: J5i Ar Amount. 0 �Z/ completion of well construction to the county health department of the county
i
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22 2016
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