GW1-2022-06283_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
o c cell 1 Q Vs e. 14:.WATER ZONES--,'.
Well Contractor Name FROM TO DESCRIPTION
IL
14S50 �{- ft It. ft.
ft.
NC Well Contractor Certification Number
11
is;OU�'ERNsING,(16� multi-,as a wais)OR igNER(if a"lic Ae'-, :::.::'
Morgan Well & Pump, Inc. FROM jTO- DIAMETER THICBaIMSS MATERIAL
+1 ft ft 61/6/ in. sdm pvc
Company Name
4E NG OR,TVEINa k eotlier`mal rlo'sed-Iod`
2.Well Construction Permit#:Wf b�_ �11— l� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(z e.WC,Couniv,State,Ymiance,etc.), ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
FROM TO DIAMETER - SLOT SIZE .THICKNESS MATERIAL.
Agricultural nMimicipal/Public ft ft in.
Geothermal(H ating/Cooling Supply) ErResidential Water Supply(single) ft ft in.
I Industrial/Commercial DResidential Water Supply(shared) - -
!Ini lion FROM TO MATERIAL - EN LACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'Monitoring DRecovery ft. ft
Injection Well:
�!Aquifer Recharge Groundwater Remediation ft it
19:SAND/GRAVEL•PA C. if a"licabre
• 'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMyLACEMENT METHOD
Aquifer Test [3Stormwater•Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) !Tracer :20.DRILLING.LOG'(attach°addi[ion'slsheetsifnecess
Geothermal(Heating/Cooling Return) 0 0ther(explain under#21 arks) FROM To D CRIPTION(color,hardness,soil/rocktype grain sue etc)
4.Date Wells)Completed: Well ID# ft .ft.
5a.Well
�Location: ,j, �},[� ft 66 f- fbl,- X�.
I Vr7 e 4-�'rl Ci Ct` V�J�:V+ _ ' ft ft n /ten
Facility
/O
wner Name Facility lD#(if)applicable) ft ft
ft ft
Physical Address,City,Ad Zip f
C,�l�'klN6q "/7��k(,/GA�iy n�A>xr�s'. :;;:-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
( �del�Ul ,s _0 ufficient) 22.Certification:
6 �
N W etc
6.Is(are)the well(S)�#,Permanent or OTemporary Si.-nature of Certified Well Contractor Date((
Or By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or*No with 154 NCAC 02C.0700 or ISA NCAC,02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the natm•e of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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:_ - 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 day§ of completion of well
For multiple wells list all depths ifdifferent(example-3(200'mud 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 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
I above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 0"Ir g construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
9� air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) t Method of test: g
Q the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: IrRACA Gar Amount: j completion of well construction to th`e 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