GW1-2022-08541_Well Construction - GW1_20220503

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WELL CONSTRUCTION RECORD (GW-I), For Internal Use Only: I
I.Well Contractor Information:
14:.WATER ZONES
Well nhactorName FROM TO I DESCRIPTION Y
ft ft
ft ft
NC Well Contractdr Certification Number 1.
15;OU2'ER,QAgNG,(foc multi-dised-wells)OR mom(if-'livable' ::'',::'•."
Morgan Well &Pump, Inc. FROM TO" DIAMETER I THICKNESS MAzrex.
Company Name +1 ft ft 1 61/61 i m, sd21 pvc
f I y 16.-ROMR C 4MNG OR•TUBING.' eothermal'clo-sed loo'
2.Well Construction Permit#: ( L I CEO FROM TO DIAMETER THICKNESS r+ MATERIAL
List all applicable well construction permits(z.e•WC,Cowziv,Stale,Viulance,etc)- ft ft in.
3.Well Use(check well use): & ft in.
Water Supply Well: 17_-SCREEN'.:.'.:
FROM I TO I DIAMETER SLOT SrM THICKNESS I MATERIAL.
1 Agricultural MMunicipal/Public ft. fL in,
_:]Geothermal(Heating/Cooling Supply) ,Xi Residential Water Supply(single) ft ft in.
I Industrial/Commercial DResidential Water Supply(shared)
:2*18:GROUT-:'. ;- N _. •.•...:t: :.. :. :: -
i hri anon FROM TO MATERIAL - EMPL4CEMENTMETHOD&.4MODNT
IlExperimental
-Water Supply Well: p ft. 2p R hentontte poured
onitoring Recovery ft. ft
ction Well:
ft. ft
uifer Recharge Groundwater Remediation
•:19:SAND/GRAVEL-PACK rf a`livable •,
uifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
uifer Test O Stormwater Drainage ft ft
Technology ; Subsidence Control ft ft
othermal(Closed Loop); Tracer :20.T)RILL1IIG.LOG-(ittacti'sdditiothermal eatine Coolie Return) FROM To DESCRIPTION(color,hardness,soil/rock type in size,etc,
g ) �Other(explain under#21 Remarks) ft
t.-
4.Date Weil(s)Completed: +(0_V Well IU# ft ft (\ LkC
5a.Well Location: R R w/I o b
11,
1 la5} ao sies ft -Lap ft 0 - OLA;ff
Facility/Owner Name `-' Facility M#(if applicable) ft t f
2310 'l e:Po Ga C L�'� 3—T ft ft
—Physical Address,City,and Zip ' ft ft
21:REMARKS'?.:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(ifwell field,one lat/long is sufficient) 22.Certification:
L / B:w lei
_gua� � i /
6.Is(are)the well(s) Permanent or Temporary Si, e of Certrfed Well Contactor Date
�{ By sip ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or !No with 15.4 NCAC 02C.0100 or 15A NCAC 02C,0200 WeH Consruction Standards and that a
Ifthis is a repair fill out known well construction ififormation e'�d`'explain the nature of the copy of thii record has been provided to the well owner.
repair under 421 remarks section or on the back ofthisform.
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 bf wells construction details. You may also attach additional pages if necessary.
drilled:
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 ifdifferent(example-3@12000'mid 2Q100� construction to the following:
10.Static water level below top of casing: Li (ft.) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
r L(i.e. ry,e.auger;rota cable,directpush,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1D!�^ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: I/ / 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 I. Revised 2-22-2016
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