GW1-2022-04444_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W tractor Info
Q •14:.WATERZONES:'. '::
Well Con Name FROM I DESCRIPTION
ft ft I
�..L � & ft
NC Well Contractor Certification Number
15:OU,I'ER_aASING,fdr multi,r ea wells OLt LIIZExt(if a'licahle)'-;
Morgan Well&Pump, Inc. FROM T DIAMETER THICIfiVESS MATERIAL
Company Name +1 ft ft 61/8/ in. sdr11 pvc
p y %n^/ p�1 16�A�II�R CA G Olt•TIIBIIVG.''eotfiermal•clo'sed-rod' - "" "
2.Well Construction Permit#: V+"" V l TO DIAMETER THrC1[NESs `•nMATERIAL
List all applicable well construction permits'(.e UIC,County,State,Variance,etc)• ft ft in.
3.Well Use(check well use): ft.
FROM ft in.
Water Supply Well: IVSCREEN'.=:. .<. `_:. . :`:.::- :.•>• ::=... .
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
AgriculturalMuaicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring DRecovery ft &
Injection Well: ft ft
_j Aquifer Recharge Groundwater Remediation ly.SAND/GRAVEL'PACK rf a"]icable r'
Aquifer Storage and Recovery ®I(Salinity Barrier FROM TO MATERL4L EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage- fL ft
i Experimental Technology Subsidence Control ft fL
i Geothermal(Closed Loop) DTracer :20.DRIILIlVG.LOG'(attactisddition'sl s3eefsi2 neces'sa'j S:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION.(mlor.hardness,soil/rock ty rain sire,ett)
e.� ft. %6 ft.
4.Date Well(s)Completed 3b !.!�' Well IN ft
5a.Well Location: ft. 112>1t
ft ft
Facility/Owner N p aAuliyy_/,Z�AFacility #(if ap licable) ft ft
1 A 1 ft ft
^Physical Address,City,and Zip Z$� ft. ft
�S 4 .-21:RP,MAItE:S't��:;:�;:-i-a-. :--.,-_i_-r•:...,__._:^:.:-:::.:`•(::'::'._:.
r 051ty Parcel Identification No.(PIN) 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) b 22. lion • ` ve W"'j ,
3S.335`b "N �,e42.1g V
6.Is(are)the well(s)OPermanent or OTemporary Si e o rtified Well Contractor Dat
signin is form,I hereby Cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or �No with ISA CAC 02C.0100 or 114 NCAC 02C.0200 Mell Conshuction Mandm•ds and that a
I,'this is a repair•,fill out known well construction information and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: r SUBMITTAL INSTRUCTIONS
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(example-3@200'mrd 2@100) construction to the following:
10.Static water level below top of casing: 3� (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 Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this jform within 30 days of completion of well
12.Well construction method: r 0 L� construction to the following:
(Le.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&Injection Wells: In addition to sending
13a.Yield(gpm)�� i
_ Method of test: g the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ : Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources •I Revised 2 22-2016