GW1-2022-05817_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GQC C94 C 1 Q USe 14:.WATER ZONES C. .. :..... .... ... .. .. . .
Well Contractor Name FROM TO DESCRIPTION
gSS0 r �- ft � ft
ft ft I ';
NC Well Contractor Certification Number t
'15:OUTERCASING,moi multi-rased wells Olt LIlYER(if a'licihL:' :
Morgan Well&Pump, Inc. FROM I TO' DIAMETER Y'HIC1Si1FSS MATMUAL
Company Name +1 t ft 6 1/a/ in' sd,21 pvc
16"uom CASING OR-TUBING.Tk66th'erm2l'c16se&lou'
2.Well Construction Permit#: FROM TO D I THICKNFMS •:.•.MATERAL
List all applicable well construction permits'rL e.UIC,Cavity,State,Valiance,etc-), ft. ft m.
3.Well Use(check well use):
R ft in.
Water Supply Well: 17_SCREEN', :. .`�: =.`_..:::.::'r -- ::•',. ',:::.::.,.:r:;.. .:=
FROM TO DIAMETER SLOT SIZE TFIiCKNFSS MATERIAL.
Agricultural CDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooliag Supply) Residential Water Supply(single) ft ft
I Industrial/Commercial E3Residential Water Supply(shared) -
b firi ation FROM TO I MATERIAL EMPIACEMFNTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentontte poured
Monitoring oRecovery ft ft.
Injection Well:
ft ft
J Aquifer Recharge Groundwater Remediation
19:SgND/GRAVEL'PACB rf a"lica6Ie
Aquifer Storage and Recovery OSalinity Barrier FRoM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage fL ft.
I Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) Tracer :20.DRILLII�TGLOG(attacliaddition'aIslieetsafnecess
Geothermal(Heating/Cooling Return) Other(explain under#21 ) FROM TO DESCRIPTION(color,hardness,soiltrack in s ze etc)
/� ft
4.Date Well(s)Completed:, — ^2 Well ID# // ft. t rbLW-► �y
5a.Well Location: \\ (pl� t 1, ft �\
ft ft 1A V r0✓1A K—
� � s �
Facility/Owner Name Facility M#(if applicable) ft.`�
Physical
/Address,City,and Zip ft, ft
� R4
VKS�Vti �.•� O y \6 21:RF.M6RKF - '•:i _ - �:-
County Parcel Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if yeid,one lat/long is s cient)N I 22.Certification >r(5 ; �aa' ��
262 6
6.Is(are)the well(s) Permanent or ©'(Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or 14No with ISA NCAC 01C.0100 or 15-4 NCAC,01C..0200 Well Construction Standards and that a
If this is a repair,fin out known well construction Aiformation and explain the nature ofthe copy of thii 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 Qosed-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 bf 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 1fdifferent(example-3@200 and 2@I00) 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.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 form within 30 days of completion of well
12.Well construction method: 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 2 7699-1 63 6
13a.Yield(gpm) ` Method of test• air pressure 24c.For Water Supply&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: Cy�e+� Amount: completion of well construction to the county health department of the county
where constructed. f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2 22 2016
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