GW1-2022-08518_Well Construction - GW1_20220906

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WELL CONSTRUCTION RECORD QW-1) For Internal Use Only.
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1.Well Contractor Information: r
FROMATER ZONES , :-L...•r:. :'r'
Well ContractorNLme FROM TO DESCRIPTION
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NC Well Contractor Certification Number 15;O u ER_CMXNG,for multi eased weIls)O#t LII iE1t ifa
Morgan Well &Pump, Inc. FROM 1 TO' Dr TEx' THI rCK�Ss MATFRLA-
+1 & fL 61/6/ in, sdr21 Pvc
Company Name 16."IIWM CASING OB•TDBING: 'eothefind closed-hid"
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2.Well Construction Permit#f: l b61 t FROM TO DIAMETER T�clss MATERIAL
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List a applicable well construction permits'(ie.WC County,State,7-1--,etc)' ft
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ft ft. in.
3.Well Use(check well use): .-•:_, _ .. . ;
M SCREEN'.
Water Supply Well: >•ROM TO DL.METER SLOT SIZE ~THTCKMS MATERIAL.
Agricultural EDM al/Public ft ft in.
Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft in.
Tndustri Commercial i Residential Water Supply(shared)fN
'on FROM TO MATERIAL IIaI.4CEMENTMETHOD&AMOUNT
ater Supply Well• 0 ft 20 fL bentonite Poworing [3Recovery ftn Well: ft. ft
er Recharge [3 Groundwater RemediationACg rf a er Storage and Recovery SalinityBarrier FROM TO MATERLA M PLAC 2&t&I iviETgOD
r Test OStormwater Drainage ft ftmental Technology Subsidence Control R fL
ermal(Closed Loop) DTracer :ZD.�RILLJNG.LOG'aitsc]iaddition'slslieed faHFROM TO D CRIPTION(color,hardness,soiUroek e, size,ete)
ermal(Heating/Cooling Return) i Other(explain under#21 Remarks) ft
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4.Date Well(s)Completed: �^ `'�' Well ID# • ft ft. / G
ft5a.Well Location:
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Facility/Owner Name Facility ID#(if applicable) ftSE
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&(45 (A/d,-J&K4 Ar N�tr Ae ft ft
PlrysicalAddress,City,and Zip %QG < t ft ft
1 (y�'��J�.74 :21cR�,b1'A—RTlR
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.C catio .
35'.'5660 -N —9l, 03C3 W g �-
6.Is(are)the well(s) Permanent or Ci Tempo;N�10
Si o rtifi a nttactor Date
By signing this form,I herebv rarhfy that I the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well �I Yes or with ISA NCRC 02C.0100 or 15A NC4C 02C-.0200 WeD Construction Standards arrd that a
Ifthis is a repab•,fin out brown wen construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform 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: . - I ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells List all depths tf different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 36 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor-ehoIe diameter: 6 (in.) 24b.For Iniection WeIs• In addition to sending the foul to the address in 24a
f above,also submit one copy of this:form within 30 days of completion of well
12.Well construction method: �Q �LR construction to the following-
(Le.auger,rotary,cable,direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELL&ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: aif pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
MM--��"�IrW—1 Amount: 1 the address(es) 'above, also submit ;one copy of this form Within 30 days of
13b.Disinfection type:(..M�1pS a2 completion of well construction to the county health department of the county
where constructed
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Revised 2-22 2016
Form GW-1 Nortb Carolina Departrnent of Environmental Quality-Division of Water Resources :