GW1-2022-06235_Well Construction - GW1_20220701

WELLCONSTRUCTION RECORD (GW X) For Internal Use Only.
eU.,Contractor Information: -
l l .•.
r 1�►�—ToP� 14:. ATERZONES:•. - r .• :.::
WCelllContrr..ttmr am/ee' ' , FROM TO DESCRIPTION
ft ft
ft ft
NC Well Contractor Certification Number
15;OUCER.CASING'(for mniti=riged wells)OR L7IQE)2(if licahle)' :=::'.:.: -.`.;
Morgan Well &Pump, Inc. FROM TO' DIAMETER THICKNESS MATEPJAL
Company Name +1 ft ft 61/81 m' sdr21 pvc
�� 16:`IlIIQER CASING OR•TUB3VG. eothefiiuiI clu'sed 66
2.Well Construction Permit#/: ['T W l J / FROM To I DIAMETER I THICrQ1Ess - MATMUAL
List all applicable well construction penndits'(ze.b7C,Cow*,State,Variance,etc.)* in.
3.Well Use(check well use): ft ft in.
Water Supply Well: IV SCREEN*, :;. .`•�; •.:•::.: ::-(,.: ;•: r
FROM TO DIAMETER SLOT SIZE THICKNESS TvrATERIAL
Agricultural CiMunicipal/Public ft ft in.
1 Geothermal(Eeating/Cooling Supply) FIResidential Water Supply(single) ft ft in.
rndustnaUCommercial i Residential Water Supply(shared) ;18: 0�,:: .. ;,• ..:,,. _:. -• - _
I Isi ation FROM TO MATERIAL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft bentonite- poured
'Monitoring Recovery ft ft.
Injection Well: ft ft
-_I Aquifer Recharge Groundwater Remediation
•.79:SAND/GRAVEL-PA:CI{if a"h kbla ':...._ .:'. ..: •.: : ';. ':•`
Aquifer Storage and Recovery MSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13stormwater Drainage ft ft
Experimental Technology OSubsideuce Control ft ft
Geothermal(Closed Loop) UTracer :20.DRILLING.I OG'(attac5'additii n'aI slieetsiffiecess -);:':; =i
Geothermal(Beating/Cooling Return) 0 Other(explain under##21 Remarks) FROM I TO I DESCRIPTION(cooler,hardness,soil/rock type,grain size,etc)
4.Date Well(s)Completed: ell ID t't ft.
�� C.�s
Sa.Well Location: ft ft �Ld
r1(1 5 ^^1
ft-
Facility/Owner Name Facility ID4(ifapplicable) $ f. 2 ft Vx-
{/ l/� ft ft
Physi1calAddress,City,and Zip ft ft �„';' '_ �s V s'`�ey$
County Parcelldeutification No.(PIN) JULf 0 1
_ '-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �. ;;;_, .. _ t u •
(if well field,one lat/long is sufficient) 22.Certification'
N Of. [6yA 5 W �2g-22
6.Is(are)the wells) Perrnanent or E3Temporary Signature of Certified Well eontractor Date
rev By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or It_I PO with 15ANCAC 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information ankiNplaln the nature ofthe copy ofthii record has beenprovided to the well owner.
repair under#f21 remarks section or on the back of thisfomL 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 to
additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 11J[' (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100D construction to the following.
10.Static water level below top of casing: 00 (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 Injection Wells: .In addition to sending the form to the address in 24a
f above,also submit one copy of this foam within 30 days of completion of well
m
12.Well construction ethod: A LI constmction to the following:
(Le.auger,rotary,cable,directpusl-,etc.)
FOR WATER SUPPLY WELLS,ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a Yield(gpm) Method of test: air pressure 24c.For Water Suuuly&Iniection Wells: In addition to sending the form to
A, the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: �O/ll`'3` Amount: I 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 2 22 2016