GW1-2022-05629_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Wall Contractor Information: /} '
c �Q USA 14:.WATER ZONES
Well Contractor Name FXam TO DFSCRiPTION
11SSO— 14 ft
ft ft
NC Well Contractor Certification Number
is;OUTER.CASING,(foc rulti rased wells)OR 1mR(if a"lirahle),
Morgan Well&Pump, Inc. FROM TO' I DIAMETER I THICKNESS IMATERTAL
+1 ft ft 61/a/ in' sd,21 pvc
Company Name O /
l/J� �-{` 16:IIII�TER CASING OR•TCTBING. eotlier'malclo'sedadd"
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construcdonpermits'(.e.UIC,County,State,Variance,eta} It I
ft in.
3.Well Use(check well use): ft .f in.
Water Supply Well: 17:SCREEN',:,:..: :::;:rr':.•i t ..:' ::=.. .-r::.:. .::
FROM TO DIAMETER SLOT SrZE THICKNESS MATE AL.
Agricultural CDMunicipal/Public fL ft in.
.Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I Iudustrial/Commercial E3Residential Water Supply(shared) 18.GROUT:: " " `-'•; - '-
ation FROM TO MATERIAL - EMPI.ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft ft
Injection Well: fc ft
J Aquifer Recharge Groundwater Remediation ,,19.S,&ND/GRAVEL PACKCif a"licalile
Aquifer Storage and Recovery CISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test j3Stormwater Drainage ft ft
i Experimental Technology EISubsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRMUNGSOG(atti6additidn'alslieetsjdaeces's
Geothermal(Heating/Cooliag Return) i Other(explain under#21 ) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.
ft d ft r�,
4.Date Well(s)Completed: �'��TL Well U)# -v ft O �yG r1
Sa WJJ Location:/ - / U ft 0 S'
95
Fiility/Owner Nametl FacilityID#(ifapplicable) `gig a
�3 ck(I bko j C -f i as 1t ft ft202
Physical Address,
pCity,and Zip I �1 i ft. ft
/`1 e.kle V a —��L-` l 21c RFMhRKR'i.' _ +; '.:5 y._r- ,11�(9(w+' Rf�
,1P� r„iJQiL�O�'
County Parcel Identification No.(PIN) 1�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lat/lo o is s tent) q( 22.Certification
Zo N So •�—WC, W 1.07,�
6.Is(are)the well(s) Permanent or OTemporary Sig-rtature of Certified Well Contractor Date
By signing this form.I herebv ceiliry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MI Yes or J No with 15A NCAC 02C.0100 or 15A NCAC.02C,0200 FRH Consruction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature of the copy ofihii record has beers provided to the 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 NUIvMER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ % 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 rfdiierent(example-3@200'and 2 00) construction to the following.
10.Static water level below top of casing: (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
( above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L`
construction to the following:
(Le,auger,rotary,cable,direct pusli,etc.)
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) /�.7 Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
��yy q r the address(es) 'above, also submit one copy of this fort within 30 days of
c 13b.Disinfection type: C�envl r Amount. /Yak" completion of well construction to the county health deparhnent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016