GW1-2022-06177_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only:
I.Well Contractor Information- �y
7qc{e}-� �1(k s � •14..WATERZONES•:•.
well Contractor Name FROM TO •DESCRIPTION -
ft ft
v ft ft
NC Well Contractor Certification Number
15;OD7ERGtASTNG,(&a multi=rasea wells)ORLMgER(ifa"'llco l)' ;`'.::'•.
Morgan Well&Pump, Inc. mom Jo
DLQMTER, =clmisss M?TTr.RTd7.
Company Name +1 ft $ 81181 I in' sd21 pvc
Iti:Il�II�RCe1S�TG08"T[7BIIVG'"eotfiermal•cio'sed-hod
2.Well Construction Permit#: II
��1 5 FROM To DL MRTFR ITI"� MATEPJAL
List all applicable well construcdon permits'r e.UIC,County,State,Farlmce,etc/ ft• ft. in.
3.Well Use(check well use): ft in.
Ri
ater Supply Well: 11-SCREEN',=.. ::._. .` _ :',.:__,;._:•: .._,.: :;.. .:
� FROM TO DIAMETER SLOT SIZE THMENESS MATERIAL.
Agricultural L_1MunicipalTablic ft ft in.
EGeothermal(Heating/Cooling Supply)- eside dal Water Supply(single) ft ft
Industrial/Commercial E3Residential Water Supply(shared) I8:GRODT::., - - -
rGeothermal
tion FROM TO MATERIAL'- BrOIACEMENTMETHOD&-AMOttNT
ater Supply Well: 0 ft 20 ft• bentonite• poured
oring Recovery ft ft
n Well: ft ft
er Recharge MGroundwaterRemediationer Storage and Recovery15alinityBamer om oriEMPLACEI�A TivmETHODr Test 0StormwaterDrainage ft ftmental Technology Subsidence Control ft ftrmal(Closed Loop) Tracerrmal(Heating/Coolirrg Return) J Other(explain under#21 ) FROM TO D CRIPT ON(color,hardness,soillmektype,v a n size,etc.)
4.Date Well(s)Completed:y Well ID# J ft /tyty w
Sa.Well Location: - / ft Od ft .•� (' ���• '
�S 4J. PC, t ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
Phys1c,aJ1A4$rcss,City,and Zip �/) ft.
/ /
County Parcel Identification No-(PTJ� / -^^ t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tfwell d one lat/long is sufficient)
^/fJ 22-Certification:
G
6.Is(are)the well(s) Permanent or ©II Temporary Signature of Certified Well Contractor Date
By signing,this form,I hereby cerfify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or° I No with 15A NCAC 02C.0100 or IS14 NCAC 02C..0200 Mell Construction Standards and than a
If this is a repair fill out known well construction hiformation and explain the nato•e ofthe copy ofthis record has been provided ID the well ow•rrer.
repair under*21 r•emarkssection or on the backofthisform. 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: ' A - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -5,0 6 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differentxmple-3a00 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 casino 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
12.WeIl construction method: d r L[ above, also submit one copy of this form within 30 days of completion of well
(I.e.auger,rotary,cable,duectpush,etc.) construction to the following:
EWATFRUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit one copy of this form within 30 days of
type:��l'4A01 os- Amount: 1 b 2— completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Deparbnent of Environmental Quality-Division of Water Resources Revised 2 22 2016