GW1-2022-06524_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ontracto ation:
:. -
14:-WATERZONES
FROM TO DESCRIPTION
WellC rName ft ft.
ft ft
NC Well Contractor Certification Number
15:OUTER:CA.SING,(foc multi cased-wells)0R_L'IIgER hf--'licaltle.s:=::'.:
Morgan Well&Pump, Inc. FROM 1 TO' DIAMETER TmcIams MATERIAL
Company Name +1 ft ft- 61/a/ 1 c in' sd,21 pv
//��/f� � 16:;SVNERCASINGORTOB7NG.' eothermal•clo'sed-rod`: `'•`' �• •
2.Well Construction Permit#:V I' FROM I TO DIAMETER I TEaCKNEss I•MA'rF RUL
List all applicable well construction permits'(1.e.UIC,Comity,State,Variance,etc.)- ft ft in.
3.Well Use(check well use): ft 'f in.
Water Supply Well:
IVSCREEN•.O:..z `-"-'DIAMETER•-- :.•••.• r.i':.. a ..-: - _;:-.
i1ndustrial/Commercial
- .. ..•. .�. ,. :. -.,..:;. .�.;..•..:•.• .•:
VROM
SLOT SIZE TATCKNFSS MATERIAL.
Agricultural �MuaicipaWriblic ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in•
Residential Water Supply(shared) GROUT-.`.
., ..
•.hri atiOn FROM TO `MATERIAL -- EMPLACEMENT&rETEOD&AMOUNT
Non-Water Supply Well: p ft 20 ft bentonite poured
Monitoring [3Recovery ft ft
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
•.19:S,M/GRAVEL-PA-CK if a "ii6bre
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage- ft ft
_I Experimental Technology OSubsideace Control ft ft-
Geothermal(Closed Loop) DTdcer :20.DRIILLING.IAG'(attactisddition'sl sli'eetsifaeces's_'j':{;'- -'=
I Geothermal(Heating/Coohng Return) ril Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,soiltrack type,grain size,etc.)
0 .ft- 2.0 ft YbV.V% V+
4.Date Well(s)Completed: 3o ZZ Well ID# 20 ft 35 ft
Sa.Well Location: 3 ft ft
ft ft ,
Facility/Owner Name" Facili ED#(if applicable) ft ft
Ltwt, 1 l \ 1`lA.. ft ft
P ysical Address,City,and Zi Z�Yn ft
LAbyN' n r LJ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: mAy _• 3
(if well field,one lat/long is sufficient) cation:22.
T r r,xm�,ow na,
6.Is(are)the well(s)oPermanent or aTemporary Si of rtified Well Contractor Date
mining form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 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.
dried' % IIC 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 1(a3100) construction to the following
10.Static water level below top of casing: AAO (ft) Division of Water Resources,Information Processing Unit,
,Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole 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: r r L� construction to the following:
(i.e.auger,rotary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp ) air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield m Method of test: g
f`� the address(es) 'above, also submit,'.one copy of this form within 30 days of
13b.Disinfection type•1*��- Amount: completion of well construction to the county health department of the county
where constructed_
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Form GW-I Nortb Carolina Deportment of Environmental Quality-Division of Water Resources Revised 2 22-2016
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