GW1-2022-06241_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GV4r-1) For Internal Use Only.
1.Well Contractor Information: ,,
Tay Tod 4 U`? 14:,IWA.TERZONES
Well Contractor Name FROM TO DESCRIPTION
^� ft ft
ft ft.
NC Well Contractor Certification Number
l 'I5:OUTER:WING,(&n lhulti-rasea*Es)OKmNERa
Morgan Well &Pump, Inc. I DIAMETER I THICErITEss MATERLL
Company Name .i ft. , ft 1 61/8/ in. I sdr21 pvc
-7/� I6"IDI1�It CASIN OR•TL7BlNG`•e6tTiermal closed-lod' : -- ••
2.Well Construction Permit#:_ v _ O�] !V FROM To DTdn Fa TSiclNEss MATERIAL
List all applicable well constructionpermits'(r.e.UZC,Countv,State,Variance,etc)- ft fL in.
3.Well Use(check well use):
ft ft im
Water Supply Well: 1Z SCRFFENN', .: :s_;. -`�: ••;•.`:.: :.::i:.•i• ;..:�,:'::;:- �.-r:;.:. .::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
__Agricultural 0MunicipaUPublic ft. ft in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft In.
I]ndus 'al/Connumcial I Residential Water Supply(shared) __:,•,.:,:.,,_ - -
:Iiri ation FROM TO `MATERIAL EMPL.ACEMKNT METHOD&_4MOIINT
Non-Water Supply Well: o ft 20 ft bentonite• poured
Monitoring DRecovery ft ft.
Injection Well:
_1 Aquifer Recharge [3GroundwaterRemediation ft ft
Aquifer Storage and Recovery Salim Barrier &&ND/GRAVEL PACK Cif a"livable `
q g �y Salinity FROM TO MATERIAL . -EMPLACEMENT METHOD
I Aquifer Test Ql Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) j3Tracer :Z0.DRILLING LOG(attach=addition'aI sliee£s if necess"')';'�::'=:: :_
Geothermal(Heating/Cooling Retum) I Other(explain under#21 Remarks) FROM To DESCRIPTION(color, ardness,soil/rock type grain size ate)
r_ 7 a .fl, 4o ft t
4.Date Well(s)Completed:l0 '�/L Well ID# Ll
C7 ft ft'
5a.Well Location: S� ft 1 ft rgpNt/` Q aGC(
Facility/O
w
ner
Name Facility]D#(if applicable) ft. f
ft ft
Physical^Ad^^drres�s,, t
�City,and Zip ft f
�• V 4t.)' `D��"� -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C
6.Is(are)the wells) Permanent or OTemporary Si ture,of Certified Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing weIl: M Ives or No with 1SA NCAC 02C.0100 or ISA NCAC 02C•.0200 Well Construction Standards and that a
If this is a repair fill out known well construction hiformation nd explain the nature of the copy ofthg record has been provided to the well owner.
repair under#21 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 7.22 (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2 00'and 2@100) 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,Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0•� LL construction to the following:
(Le.auger,rotary,cable,directpush,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 Supply&Iniection Wells: In addition to sending the form to
2 ^� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: 610c e— Amount. �J O L 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