GW1-2022-08468_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.W-elLContractor Information: P
1 V 14:.WATER ZONES
Well ControlrName FROM TO I DESCRIPTION
ft ft.
fL ft
NC Well Contractor Certification Number
� '15:OU,TEReASING,foi•multi=ra;:edwells bj1 LII�*ER if'a'livable'v:�":`.:,;:' .".:
Morgan Well&Pump, Inc. FROM I TO' DIAMETER TEICENESS MATERAL
Company Name
+1 ft ft 61/8/ sd21 pvc
16:INNER CASIRG OR.TOBING "eotliermal closed lou ;'
2.Well Construction Permit#: t FROM TO DIAMETER I THICYK1gESS I MATERIAL
Liss all applicable well consauctionpermits(i.e.I17C,Catalty,State,Variance,etas R ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 1VSCREEN'.'
i Agricultural VROM TO DIAMETER SLOT SIZE I TnTcKrms MATERIAL
- gl �Municipai/Public ft ft in.
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft
Izndusfri' 7Commercial _i Residential Water Supply(shared) —GROUT:..
I irrigation FROM TO I MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft ft
Injection Well:
�-,� ft ft.
_ Aquifer Recharge Ems!Groundwater Remediation r
Aquifer Storage and Recovery Salini Barrier '19'SAND/GRAVEL-PACK Cif a"iicable •'-:.:
tY er FROM TO MATERIAL I EMPLACEMENT METHOD
['Geothermal
fer Test OStormwater Drainage ft ft
rimental Technology Subsidence Control ft fL
(Closed Loop) EITracerhermal(Heating/Cooling Retum) Other(explain under#21 Remarks) _OM TO DESCRIPTION(color,hardness,soil/rock type, n s'ze etc
0 ft ft
4.Date Well(s)Completed Well ID# `S R. ft.
e11 Lo 'o 5 f
ft O ft
toy
F _5;jj nerN`a_m`ep� FacilityID#(ifapplicable) ft. ft
lLV� VVJ\L�y�.SJ� • `kt 'Y ft ft
3.
sical Address,City,and Zip ft ft
County Parcel Identification No.(P11,T)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification lay O 2022
35,53 6 N Vo 1 ,16 W
<�z 0- ;L
6.Is(are)the well(s)SPermanent or Temporary S" a of Certified Well Contractor ,,:•, , ' ^t,l 'ya rl �;�
y si this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JFNo with 15.4 NCAC 02C_0100 or 154 NCAC 02C.0200 WO Construction Standards and that a
If this is a repair ftU out known well construction itiformation and explain the nature ofthe 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 welI'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: I W (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(200'and 2Qa 1000 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.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r O Y L� above,also submit one copy of this iform within 30 days of completion of well
12.Well construction method
construction to the following:
(ke.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VaLLS ONLY: __ ___1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6__—._—___
13a.Yield(gpm) 1� Method of test: air pressure 24c.For Water SuDDly&Iniectio I Wells: In addition to sending the form to
n the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typed 1MYV_ Amount: L tee 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