GW1-2022-05818_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:a
AaCfe�-� ClQUSe. 14:.WATERZONES.::
Well Contractor Name FROM TO I DESCRIPTION
14,550- �- '� ft ti fL
ft
NC Well Contractor Certification Number
15:OU•E'R:aASING,(fuc multi-cased wells)OR I;7>�R(if a livable)':; ::',:
Morgan Well &Pump, Inc. FROM T DIAMETER THICKNESS I MATERIAL
Company Name n n +1 ft-. ft- 118/ in. sd,21 pvc
ICINNER CASING OR TCTBIIVG. "eotfiermal c1o'sed lou' r
2.Well Construction Permit#: / VVV li FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits'(ze.WC,Cowriv State,Parlance,etc-), ft. ft• in.
3.Well Use(check well use):
ft ft
Water Supply Wen: 17--SCREEN',
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural EDMunicipal/Public ft. ft in:
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) fc ft in•
I Industrial/Commercial E3Residential Water Supply(shared)
!Irrigation FROM I TO - MATERIAL - MyeL,&CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft bentonite poured
Monitoring DRecovery ft. ft
If
jection Well:
ft ft
Aquifer Recharge 0 Groundwater Remediation 19:SgND/GRAVEL'PACK rt a "lica6le
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT r12ETHOD
Aquifer Test E3&ormwater Drainage ft.1
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRn=NG.LOG'(attiiY ddition'slslieedifiiece s_-•':{:'-r'-.=Geothermal(Heating/Cooling Return) Mother(explain under#21 arks) FROM To DESCRIPTION(color,hardness,soil/rocke n size,etc)
G .ft ft ' ,(
4.Date Well(s)Completed: Well ID# ft. /� ft. �
5 eJI Location: ft `G V ft. G %�
ft. ft
Facility/Owner Name — Facility ID#(ifapplicable) ft ft
31//8 'Pfr rkljaoJ Pc ft ft
jUN
Physic ddress,City,and Zip ft ft
�c�c-c^„ 3S63 g3 S"�7 °zl:x1•,n�xs°- - -:;- _ _ - _;;- - -t' _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 1
field o e lat/long is sufficient) 22-Certification'
3s y N W -&Z-t
6.Is(are)the well(s)AP
ell(s) Permanent or Mi Temporary Signature of Certified Well Contractor Date
v By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or tNo with 15A NUC 02C.0100 or 15A NCAC 01C-.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the naim•e of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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:- - % I �� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t (ft) 24a. For All Wells: Submit this form within 30 day3 of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100) construction to the following.
10.Static water level below top of casing: y0 (ft-) Division of Water Resources,Information Processing Unit,
If water 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 form within 30 days of completion of well
12.Well construction method: 0 LL construction to the following:
(Le.auger,rotary,cable,direct push,eta)
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&Iniectionl 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: C rtA01 a r Amount: b2' 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 222 2016