GW1-2022-06523_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
n
_lam IA(rCl �_ �01'GQI[/( 14:.WATER ZONES-,'.
Well Contractor Name FROM TO DESCRiP.TION
c J /L--A '�D ft f$4 ft.
NC Well Contractor Certification Number
15;OUTER:GASING,(foi multi-cased wells QR LIIQE1t(if'a'lirable'•t
Morgan Well&Pump, Inc. - FROM I TO DL4METER' THICMMSS MATERIAL.
Company Name 1
+1 ft. f. ft 61/81 ! in. sdr2i pvc
1 [� 16.,110M CASING OR TIIBTIVG: •eothe"rmal closed-loo` r - •,:S
2.Well Construction Permit#: 21.. 11v FROM TO DIAMETER THICKNESS '+I MATERIAL
List all applicable well construction permits'(1.e.WC,Cow4v,State,Yaiance,etc.)- ft• ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 11-SCREEN'„
FROM TO DIAMETER-- SLOT SIZE THICKNESS MATERIAL.
!Agricultural DM cipal/Public ft ft. in.:
i Geothermal(Heating(Cooling Supply) esidential Water Supply(single)
ft ft in.,
I IndustriaUCommercial E3Residential Water Supply(shared)
:GROUT'::.,.. ..
i Ini ation FROM TO MATERIAL EMPLACEMENTMEMOD&.AMOUNT
Non-Water Supply Well: 0 M 20 ft. bentonite poured
_'monitoring; DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery E=7 Salinity Barrier FROM D/G TOVE- PACK MATERIAL a
' EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
I Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) 13Tracer :20.tiRIISIIVG.LOG'(at6iFiddit1iin'0 sUets
Geothermal(Heating/Cooliag Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc
ft.
t fL
4.Date Well(s)Completed:`Y �� Well ID# ft ft S'
Sa�WjeII ft ft
Location: tv
`/tyr Soo ft ft
Facility/Owner Name r Facility ID#(if applicable) ft fL
ASO ao la H<< ! _ �oy��rd t IUG ft ft:
Physical Address,City,and Zip ft. ft . °
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ff well field,one lat/long is sufficient) ?t"-"t1a :"ttS't � ae � ,�
fj q ( � / 22.0 lion: t{.,�'vnsil 0G'L•���+,�'v� v'.r
�ISy� 1 -N "36_Y1V� 09 W
6.Is(are)the well(s) ermanent or OTempo;N10"
Sign of C ed ntractor Date
By sighing this form,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair fall out known well construction information and explain the nature ofthe 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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@200'and 2@100 construction to the following:
10.Static water level below top of casing: /S (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorefioIe diameter: 6 (in.) 24b.For Iniection 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: of (q construction to the following:
(Le.auger,rotary,cable,directpush,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniectioni Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ��� completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016