GW1-2022-06237_Well Construction - GW1_20220701

STRUCTION RECORD (GW-1) For Internal Use Only.
I.Well Contractor Information:
V (\ � •14:. A_TER ZONES
Well ContrAtorName FROM TO .DESCRIPTION '
ft ft
`I EY,10 ft ft.
NC Well Contractor Certification Number
15:OUTER:CASINCz,(fo`r mmlti=rased svelLs)OIt ITlgER(if a'IIcahle)'
Morgan Well &Pump, Inc. FROM TO' DIAMETER THEMNESS MAr1 7dS.
Company Name +1 ft.
ft• 6 1161 in. sdr21 pvc
r f r f ,/�/�_/e^'���(��J/�/ 16`INNKR CASING Olt•TIISING." eotlierma7 clo'se3lod' ?.:. - =' ;.=:
2.Well Construction Permit4:_ W 1 �/ W L� FROM TO DIAMETER THICKNESS MA'rFRTAT.
List all applicable well constructfon permits'r e.UIC,County,State,Variance,etc.)• ft. ft in.
3.Well Use(check well use): ft ft in
f—iAgdcultural
r Supply WeII 17_-SCREEN',
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
DMunicipal/Public ft ft in.
thermal(Heating/Cooling Supply) 1oResidential Water Supply(single) ftusinal/Commercial I Residential Water Supply(shared) IS: OUT.' -
Iui ation FROM To MATERTAL - EMPL_4CEMENTMETHOaAMOUNT
Non-Water Supply Well: 0 ft. 20 ft' bentonite- poured
'.Monitoring MRecovely ft, ft
Injection Well:
ft fL
Aquifer Recharge Groundwater Remediation
•.19:SANDlGRAVEL'PACK rf a•licatiIe .": - ..•,. - ;- .•,--.
Aquifer Storage and Recovery OSalinIty Barrier vQft.
TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage. t ft
i Experimental Technology OSubsidence Control t ft
Geothermal(Closed Loop) Tracer Geothermal(lleating/COoling Return) Other(explain under#21 Remarks) TO DES RIPTION(color hardness,soillrocktype grain size etc)
�4.Date Wells)Completed: L - — Well ID4 �5• ft b ft 4,-L d
SR.Well Location: �+ �} ft I ft
ft zXD ft
Facility/Own
(erName FacilityTD#(if applicable) ft. ft
1��6 7 jI ro 2a ft ft
1
Physical/A�d7d�re/s�s,City,ry,and Zip ft
r n Vi-i v l �S ��� `•ZIcl2�M:lRKC"- - `:J` _ = - _- _
County Parcel Identification No.(PIN)
LIIYii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:25
m j
(if well field,one lat/long is sufficient) II 22.Certification
6.Is(are)the well(s)41Permanent or OTemporary Sig a of Certified Well Contractor Date
By sie una this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 6N. with 154 NC,IC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consouction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back oflhisform
• 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 bf wells construction details: You may also attach additional pages if necessary.
drilled:_ it SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 (ft-) . 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3 200'and 2@100D construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
•Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
If.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r Q+-a�r L� above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following: .,
Division of Water Resources,Underground Injection Control Program,
LFOR WATER SUPPLY WELLS<<JNLIr: 1636 Mail Service Center,Raleigh,NC 27699-1 63 6
Xield(gpm) Method of test air pressure 24c.For Water Sunniv&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection type: 190 n'G Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEuvrronmental Quality-Division of Water Resources Revised 2 22 2016