GW1-2022-08594_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Cantracto,z3i,,faxtion: �
11 14:.WATER ZONES,'.
Well ctractor a FROM TO DESCRIPTION
M ft
2z"A
ft ft i
NC Well Contractor Certification Number
'15:OUT'ER:G�ASTNG',(focmnlfi=rasedvve]Ls ORI:Il�E1.2 ifa cable' :�:".�.::' .`.;
Morgan Well&Pump, Inc. - FROM TO' DIAMETER"� THICKNESS 'li MATERLS•L
+1 ft ft- 61/a/ m• sd21 pvc
Company Name
16-Dam CASING OR•TUBI r46. eothermal closed lou"
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well consnuctionpAmits(r.e.fIIC,Cowuv,State,Variance,etc)• ft ft in.
3.Well Use(check well use): ft ft rn
Water Supply Well: 17:SCREEN',:,:..<. `_:. .'�., •=`:<:- `•. ems=, :,::;.:.: ,.`F::.. ..:;
FROM TO DIAMETER SLOTSiZE THICKNFSS MATERIAL .
Agricultural r-11Municipal/Public ft ft in.'
!Geothermal(Heating/Cooling Supply) I@Resideatial Water Supply(single) ft. ft in.
I Industrial/Commercial E3ReSidential Water Supply(shared)
:rY8iGROUT•: -
'.1ai ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
'•Monitoring DRecovery ft ft.
Injection Well:
_]A uifer Recharge e ft ft
q gGroundwater Remediation :19:SAND/GRAVEL PACFC rf a"licatile7.
Aquifer Storage and Recovery F__'t'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage- ft fL
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.tiRIILING.I;OG(attach'sddition'sl slfeetsjfnecests'-'tr =., '-
Geothermal(Heating/Cooling Return) r-il Other(explain under#21 Remarks) FROM TO DESCRIPT ON.(color,hardness,saillrock type, - in size,ete
© ft. S ft
4.Date Well(s)Completed: 2 Well ID# ` ft ft
Sa.Well Location: ftgap
ft '
D fL ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
ti �d ft ft
Physical Address,City,and Zr ��S ft ft � n r �...
ty Parcel Identification Ifo. IN) MAY 0 3 2022
5b.Latitude and longitude in de.arees/miuutes/Seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)i
22.Certification:N � ,^O�
s ,
� W
6.Is(are)the wells)*Permanent or [ Temporary ry oltertified Well Contractor D
si 'n is form,I hereby ce2liify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No ISA C 02C.0100 or ISA NCACD2C•.0200 We Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofrhis record has been provided to the well owner.
repair under#21 remarks 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-I is needed. Indicate TOTAL NUMBER Of wells construction details. You may also attach additional pages if necessary.
drilled: . 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exatnp le-
-33Q2fl00'and 2@100D construction to the following:
10.Static water level below top of casing: t7`' (ft) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,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
t 12.Well construction method: above, also submit one copy of this:form within 30 days of completion of well
'r��Y LL
(Le.auger,rotary,cable,direct push,etc.) J
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
T - i
13a.Yield(gpm) V Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
r�1w` the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typed-�`. �'� Amount: 6Z completion of well construction to the county health department of the county
where constructed
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016