GW1-2022-08529_Well Construction - GW1_20220907

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only,
r _
1.Well Contractor Information:
kvN % PilVl -14:.1WATER ZONES:'.
Well CoatractorName FROM TO DESCRIPTION
ft 3 ft
'35 7 Z-A ft ft
NC Well Contactor Certification Number 15;OU7.'ERG�ASING,&&multi=rssea•wells)b_o7mlER tf''licahle'
Morgan Well&Pump, Inc. FROM TO' DIAMETER I THICKNFSs MATERIAL
Company Name +1 ft- M 61/61 m sd,21 pvc
p 16 71II�R CASING O12•TIIBING: edtliermsa clased.-loti` ,'
2.Well Construction Permit#: `?O�G� ' FttoM To Dranrt�'rirR THICKNESS I MATERIAL
Lisa all applicable well construction permtis'(i e.WC,Cowity State,Pa ianw,etc.)•
R ft in.
3.Well Use(check well use): fL ft. m
Water Supply'Well:
�-�y FROM TO DIAMETER - SLOT SIZE -THICKNESS MATERIAL .
Agricultural �Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
]^ndustnaUCommercial J Residential Water Supply(shared) 18:GROTrT-• _ r .._.:.:- -_Irrigation FROM TO MATERIAL EMpIj CEMENT METHOD&AMOUNT
Non-Water Supply Well: o & 20 ft bentonite poured
'•Monitoring DRecovery ft. ft
Injection Well:
Aquifer Recharge I Groundwater Remediation D ft
SAND/GRAVEL-PACK(if a"licabll: ":.:_:•'�::=:`' '•• '. -•�.' �..-
Aquifer Storage and Recovery Salinity Baer FROM TO • MATERIAL FrYIPLACEIl�NT METHOD
Aquifer Test 0Stormwater Drainage Barrierti ft
i Experimental Technology [I Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20..)P-U=G.LOG'(attiili:dditional sheets.ifaecess"7.` r`
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, 'grainsae,etc
ft ft.
4.Date Well(s)Completed: I q-2&ell iD# ft- b 5 ft tea; Gnu A j r 9f
Sa.Well Location: { ft. ft.f
l OM 5 I10A ft. ft -e p ¢.�
Facility/Owner Name Facility ID#(if applicable) ft :,
BUG oT—
Physical Address,City,and Zip ft &
��••//� t 1/�yr�
1NGt� 0D10f.1 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p� p 22.C tion:
ZS -N —SlJ_0754 W
6.Is(are)the well($) ;Permanent or OTempoJNo
Signature of Ce a ctor Date
By signing this form ertify,I hereby c that the well($)was(were)constructed in accordance
7.Is this a repair to an existing well: ri or with 15.4 MUC 02C.0100 or 154 NCAC 01C,0200 Well Construction Standards and that a
Ifthis is a repair;fiR out known well construction information and explain the natw•e of the copy ofthii record has been provided to the well owner.
repair under#21 remarla•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 NUNMR of wells construction details. You may also attach additional pages if necessary.
drilled: 1 JJ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: GS (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths if different(ermnple-3@200'and 2@100) 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
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: c d (LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSGONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
132-Yield(gpm) 2. Method of test: air pressure 24c.For Water Supply&Iniection&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016