GW1-2022-06239_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only.
1.Well Contractor Information:
14:. ATFRZONES..
Well Con trac or Name FROM TO •DESCRIPTION.c
ft ft
M ft fr.
NNC We11 Contractor Certification Number
OUTER;CASING',(foc multi=riled wells)OR L•II�rEFt(tf a"licahle)'.:�::'.:.::'••
Morgan Well &Pump, Inc, mom TO' DIAMETER THICEa1rESs MATIUZIA.
Company Name
+1 ft' ft- 61/s/ in. sdf21 pvc
C-���7^ 16 D CASING WER OR•TM]24G': �eothefinal closed_-16dp `.:
2.Well Construction Permit#,:: ! FROM TO DIAMETER THICKNESS I MATERIAL
List all livable well construction ermits Le ft tit is
aPp p (' UI,Coturiv,State,Ymiance,etc).
3.Well Use(check well use): ft ft in.
Water Supply Well: 17."SCREEN : :t:;. .`•� _ .+;:;•::.•: -;,.:_,:':;;.__r.. . :`.:.:::`•
FROM TO DIAMETER SLOT SIZE -TETCICMS MATERIAL•
1 Agricultural DMuaicipaYPablic ft ft
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
17ndusCommercial i Residential Water Supply(shared) YS:GROUT::•. .:; _ ?' :•:' :' = - -
Irri ation FROM TO MATERIAL EMPLACEMENTMETHOD&_AMODNT
Non-Water Supply Well: o ft 20 ft- bentanite• poured
Monitoring IlRecovery ft ft
Injection Well: ft ft
__I Aquifer Recharge Groundwater Remediation r.
Aquifer Storage and Recovery t Salmi Barrier �'sarm/GRAVES'-PACK(If a"jicabl'e
q g ry ty FROM TO MATERIAL EMPLACEMENT TVMTHOD
Aquifer Test E]StormwaterDrainage ft fr.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) 11Tracer slliLtsjffiiecess-7•:n.- =z
i Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM TO DESCRI TION(color,hardness,soillrock type,grain size,etc)
c ft ft 1
4.Date Wells)Completed: ✓�� y Well ID# 3 Q ft (1 5 ft
5a Well Location: ft 0 ft raw 0
�v 6 T�u-1 U(3A 110 s ft 0 ft lLtc.
Facility/Owner Name Facility ED#(if applicable) ft ft
LIP
ft ft-
Physical Address,City,and Zip �! ` v ft ft y�t—a_' --
2 G _..
��•, Go l �� J �V :2IcRF.MAI2KR` .J:._.- _ _ -,�'.i.-`.~:.� :-._'v _
County Parcel IdentificationNo.(PIN) JQL O 2022
5b.Latitude and longitude in dea ees/minutes/seconds or decimal degrees: y - _- ;^� Unit
(d longitude.
well field,one lat/long is sufficient) I 22.C ration: .�,.`•VJ"Q..1 k 0G,
N C)1" Z7 � W ��
6.Is(are)the well(s)ilpermarient or DTemporary Sim ture of CertKed Well Contractor Date
By signing this form,I hereby cer tiny that the well(q)w6s(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or MI No with 15A NCAC 02C-0100 or 15.4 NCAC 02C.0200 FFell Construction Standards and that a
Ifthis is a repair,JIH out known well,const ucdon information offexplain the nature ofthe copy ofthis record has been provided To the well owner.
repair under 421 remarks section or on the back ofthis 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: �] SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: L (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: `� 0 (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 01 L" (r� construction to the following:
Cle.auger,rotary,cable,directpush,etc.)
FO:WATE:-RSUPPLY WEL L&ONLY• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27,699-1636
13a Method of test: air pressure 24c.For Water SuupIy&Injection Wells: In addition to sending the form t0
the address(es) 'above, also submit one copy of this fowl within 30 days of
13b type: i Amount: / 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