GW1-2022-06171_Well Construction - GW1_20220701

• _?`�o��:aTi.c�=�'.a.._GY�"fir
RTLL CONSTRUCTION RECORD (GW 1.) For Internal Use Only:
1.Well Contractor Information:
O�CC� I QUs 14:.WATER ZONES;'.
Well Contractor Name O TO DESCRIPTION
_ %50 ft ft
NC Well Contractor Certification Number
15;OTJ'i7;•RCASIN�,(fnc multi-cisea w611s)OR 12NER(ifa'11ciMe)'
Morgan Well &Pump, Inc. FROM TO' DIAMETER TIIICMITEss I MATERrAL
Company Name /
+1 ft' ft 81/8/ in' sd21 pvc
� 7S �-7�� � 16:II�II�R CAS7I�TG 012•TIIBII�G.'•enther`maI closed.-Iod`: ""_' :•:
2.Well Construction Permit#: FROM TO DIAMETER THCKKNESs MATERIAL
List all applicable well constructionpermits(1.a UIC,Cowtiv,State,Variance,eto.)- ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS 14fATERIAI,.
Agricultural ��"i MuaicipaUPublic fL ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
I IniiusfriaUCommercial E3Residential Water Supply(shared) ..18r GRO OT:;."
on FROM TO •,MATERL4L •:: E?,2i&CEMENT METHOD&AMOUNT
I�Ton Water Supply Well: o ft 20 ft bentonite' poured
Monitoring ORecovary ft. ft.
ection Well: ft ft
_I Aquifer Recharge t�Groundwater Remediation
CTC(If
Aquifer Storage and Recovery CISa]inityBalrier FROM D/PTO • p� I MATERIALe EMl`LACE0Y_NT1=01)
i Aquifer Test E]Stormwater Drainage ft- ft
_i Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) iTracer :20.DRMUNG.L'OG'(attact=addifiorislslieetsifn`ecess
I Geothermal(Heating/Cooling Retum) ril0ther(explain under#21 a111S) FROM TO DESCRIPTION(color,hardness,soillrock type,grain s ze eta)
2 L �� � D,,- �
4.Date Well(s)Completed: 6�P�� Well ID# ft a ft 13 co l v4
52 Well Location: 1 f J ft CS ft :-..<,•i N ° $�'
�I
O ft L p fty']�Farfflty/��O//w�ner Name / Facility ID4(if applicable) Z oft n a s ft 7� g� ,� `'2 2
�'l6G S�-o1�s Ferry Cad C'�1�H:� q,,+h
PhysiccjWv dress,City,and Zip LOC>ft 1196C-> ft (/✓ I k, (4
07 yC/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifefi one e ogU 0 nt)
� 22.Certification: _
J �
6.Is(are)the wells) Permauent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cet•tify that the well(s)was(were)constructed in accordance
?.Is this a repair to an erdsting well: QYes or ti No WWI 15A NCAC 02C.0100 or 1SA NCAC 02C•.0200 Wa11 Construction Standards and that a
If this is a repair,fill out known well consL•ucaon information and explain the natu,-e of the copy of this record has been provided to the well ow7ter.
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: ' I I ^^\\ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2 00'and(2@1�00) construction to the following.
10.Static water level below top of casing: Fr' (ft.) Division of Water Resources,Information Processing Unit,
•Ifwater lei+el is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection 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: Y L6 construction to the following:
(Le.auger,rotary,cable,directpusN etc.) '
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuppIy&Iniection Wells: In addition to sending the form to
oaf the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: c �Ay�Gar Amount: /'7d completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Departtnent of Environmental Quality-Division of WaterResources Revised 2 22 2016