GW1-2022-05605_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.W ontractor Informratiton: C
•14:.WATFSt ZONES
Well
lCCon rName FROM TO DESCRIPTION
1 0� A 6 ft _ f
ft ft
NC Well Contractor Certification Number
15..OUTER,CASING,for multi='eased w6lls)ORIMVER(ifa' 'licah •s le :=::`.`.::'
Morgan Well&Pump, Inc. FROM
Company Name T DIAMETER THICKNESS MATERIAL
+1 ft ft 6 1k8/ " in. sd2t pvo
•, ,
2 �� 16.71VNER C' SING OR•TCTBING eotliermal closed lod' ''i' ,::%
2.Well Construction FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well constructlonpermits(r.e.WC,Co-giv State,Variance,etc)- ft ft in.
3.Well Use(check well use): ft• in.
Water Supply Well:
FROM TO DIAMETER -SLOT SIZE -THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft ft
Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single) ft. ft
I lndustrial/Commercial DResidential Water Supply(shared) ISrGROlTT:.." :: _ {```. :"- : •::: -
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite' poured
'Monitoring DRecovery ft ft
Injection Well: ft ft
-!Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL'PACK rf a:"licabl
Aquifer Storage and Recovery nSalinity Barrier- FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Q1Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop Tracer :20.tiRIILIIVG.LOG'(attach'additianalalieets�fueces's'- ': ;'•:';s
Geothermal(Heating/ ooliag Return) Other(explain under#21 Remarks) FROM TO DESCRIP ION(color,hardness,soil/rock q grain size,etc
t ft 1p
4.Date Well(s)Completed: '�-tqzl, Well ID# Z v ft O ft
Sa.Well ocation: V ft �(� fl. 7r� �Lvrr
ft. ft
Facilil//O/wwnerNam`ee Facility M#(ifapplicable) ft ft
,5Z / ` (O�JR/t A�- ���iL� �1/( V,/� ft ft
Pliysi a!iddress,City,and Zip r/ e�f ft ft
" Uri
DQZ�Jv��..- - - --- -- — -----_ - S-�^-,=,rd•". •.
'21:I2EMARKS= •'t•�a:
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
3 ,0603�1 N (n�. ����� w 22.Cer' cation: •
152tr
6.Is(are)the well(s) ermanent or 13Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby ceyliry that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or I No with 15ANCAC 02C.0100 or 15,4 NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out brown well construction information andexplain the nature of the copy ofthis 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: - /y 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(trample-3Q200'and 2Q100') 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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: r o"Y LI
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
G the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: •1+�t7�y Amount: �V Z- 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 Revised 2 22 2016
i