GW1-2022-06236_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-X) - For Internal Use Only.
1.Well Contractor Information:
-70 1
�1 dA " 14:. 4TER ZONES
Well ContraAr Name FROM TO I DESCRIPTION
SC( —A
ft ft
/f[fir ft ff.
NC Well Contractor Certification Number
1 '15:OU2'El?rCAS1IYG'.(fnrmniti=rasedw91s)ORLIlK WCtfa'licahle)'1;�::',:,::••.`.:
Morgan Well &Pump, Inc. FROM TOI DIAl1MTER I THICKNESS LMATMUA.L t
Company Name +1 ft. S ft 6 1& m' sdr2l pvc
J� 16.DUM C' G OR•TC7BII�G.''eotiierma7 clo'se3Iod'
2.Well Construction Pa... �L 4 ZZ_0�(lp FROM TO DIABMTER THICKNESS r MATERIAL
List all applicable well construction permits'(r.e.UIC,Cowniv,State,Variance,etc.)- ft ft. in.
3.Well Use(check well use): ft ft_ In.
Water Supply Well: 17_SCREEN',: `_:. .'•�<'•=•.`_ :. ::,::;,.;�:.': •' :;.:. .:=`•` .-:
FROM TO DIAMETER SLOT SIZE THICKNESS 14fATERIAI,.
Agricultural 014unicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply)
i ) aResidential Water Supply(single) ft ft in•
I Tndustn Commercial I Residential Water Supply(shared) .18.GROUT:•: .. .. _ __.,. ._.: _ _
Fq
tioIIFROM TO MATERIAL EMPL_4CEMENTMETHOD&.4M0'ONT
ater Supply Well: o ft' 20 ft. bentonite• poured
toring Recovery ft ft.
n Well: ft fter Recharge Groundwater Remediation :.:9:SAM/GRAVEL•PACIC ifa"licibli er Storage and Recovery OSalinityBarrier mom TO • MATERUL EMPLACMI MNTMETHOD
er Test DIStormwaterDrainage ft ftimental Technology Subsidence Control ft ft
ermal(Closed Loop) Tracerrmal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type grain size,etc)
s �J A O r
4.Date Well(s)Completed: b�y Well ID# C ft ft n
Sa.Well Location: `10 ft o ft Q
Lci2�� l� (�'►� Ito ft (b� ft LU
Facility/Owner Name Facility]D#(ifapplicable) ft• ft.
l� 7A 06i?asi. /A ft-
Physical Address,City,and Zip ft ft a "=Y=C, .s y 'tr>� e SK)
(,,cA 001 7 6 l _
County Parcel Identification No.(PIN) -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
- d:.17�i wiry. I�r ii
(ifwell field,one lat/long is sufficient) „r�'L Q;!n0G
�'
-N l. l�s ?s W -17 2Z
6.Is(are)the well(s)APermanent or E ITemporarp Sim a of ettified ell Contractor Date
Pdezp1ainthenaivreofthe
By sig ring thisform,I herebv ceili,fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes orNo with 15ZNCAC 01C.0100 or ISA NCAC 01C:0200 WeH Construction Standards and that a
IJiI»s is a repair fill out known well construction information copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform. 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 NUMBERbf wells construction details. You may also attach additional pages if necessary.
drilled: J SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: r �S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3(200'sand 2@100D construction to the following.
10.Static water level below top of casing: So (ft.) Division of Water Resources,Information Processing Unit,
.9water level is above casing 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
f.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpusl�,etc.) J construction to the following:
FOR WATER SUPPLY WELLSrONLY Division of Water Resources,Underground Injection Control Program,
e 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) J Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
C�(l the address(es) 'above, also submit one copy of this form within 30 days of
113b.Disinfection type: Amount. completion of well construction to the county health department of the county
where construbted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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