GW1-2022-08514_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:. /� '
FROM. TO TION
/QcCe} ,I QUSCi '14:.WATER ZONES :..
DESCRIP
Well Contractor Name , ft ft I .
�155 & ft
NC Well Contractor Certification Number 15:OU2ER o LIIR>fa'lirahle' :.:
Morgan Well&Pump, Inc. FROM TO' DIAMMW � s MATS
+1 ft 6118/ 6m' sdr21 pvc
Company Name 1
�S�
O 6:'Il�II�R C ASII�*G OB•TIIBII�G: 'eotfiermul rio's6d-1o6
2.Well Construction Permit#: FROM To Dr��Mxr�u t TMHI s MATEFJAL -
List all appfrabL we] (i constructionpm=ifs' e.UIC,County,State,Pr,1.m e,etc} ft
ft & m
3.Well Use(check wen use):
i
ater Supply Well: FROM TO DIAMETIIt~ ;SLOT SIZE -TETCKMS MATERIAL.
Agricultural E3Municipal/Public ft ft �• i
Geothermal(Heating/Cooling Supply) &LResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) >18:GROUT-.'-- :; <=r.i':"M:-:=: -' ':;:: `: r'
'Iffi ation FROM TO Me r�uTer Fdr�L4CEMENTMETHOD&AMOUNT
VAq.
ter Supply Well: o ft 20 ft bentonite poured
ring Recovery ft ft
Well: ft ft
Recharge of GroundwaterRemediation •:• .:.: 'r._:: : '. '19:S2ax /GRAVEL•PA :r Storage and Recovery DSalinityBawer FROM TO MATERIAL' EMPLACEMENT METHOD
r Test 13Storarwater Drainageental Technology aSubsidence Control ftrmal(ClosedLoop) Tracer :20,M- RIIZINGIAG'(attach=additionalsbeFROMD CRIPTION( o ha ess,soiUrock e,grain sae,mal(Heating/Cooling Return) Other(explain under#21 ) C/ ft O ft ,rr
4.Date Well(s)Completed: Well ID#/ ft � J ft.,
fo�+Cl t
5a.Well Location: d ft -7/ ft
ft ft rt lean• L.
Facility/Owner Name �acility ID4(if applicable) ft ft
ft ft
4
P sisal Address,City,and Zip -
'
County hJ Parcel Identification No.(PIN) 7Co ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IaOG
(ifwell field,one lat/long is sufficient) 22.Certification: "
t s6- W AL:!�,S'V Z027-
6.Is(are)the well(s) Permanent or DTemporar Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the wa(r was(were)constructed in accordance
7.Is this a repair to an existing well Yes or' I No with 15A NC,AC 02C.0100 or ISA NCAC 02C,0200 WeII Construction Stand",&and that a
If this is a repair,JIB out known weII construction b1formation and eiplain the natm•e ofthe copy ofthis record has been provided w the well owner.
repair under*21 7 emarkr 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 NUIYMER'ofweIls construction details. You may also attach additional pages if necessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r`� (ft) 242. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wets List all depths l rdifferew(esmnple-3Q200'and 2(7100) construction to the following.
10.Static water level below top of r2sing: 6K) (ft-) Division of Water Resources;Information Processing Unit,
I•'wafer 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 fbim to the address in 24a
( above, also submit one copy of this foffi within 30 days of completion of well
12.Well construction method: Y L` construction to the following:
(I.e.auge,rotary,cable,direetpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
132.Yield(gpm) Method of test: air pressure 24c.For Water SuuDIv&Injection Wells: In addition to sending the form to
Qr► the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type. C'U01 a r Amount: "6 1. completion of well construction to the county health department of the county
where constructed.
Revised 2 22 2016
Form GW=1 Nortb Carolina Departinent ofEnvironmental Quality-Division of WaterRcsources