GW1-2022-08623_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
t To14:.WATER ZONES
Well Contracto Name FROM TO DESCRIPTION
f ft ft
cLJ f,
ft ft
NC Well Contractor Certification Number
15;019TER,GASING,(foc multi-rasea'wells)ORT2-TER(if'a licahle -.i
Morgan Well &Pump, Inc. FROM TO' I DIAMETER THICKNESS MATERIAL.
Company Name +1 ft ft 6 118/ In, sd,21 pvc
JrI(IJ 7 /� n/(� 16:Il�TER CASIN OR•TQBIl`tG. eotfiermalclo'sed-lob`
2.Well Construction Permit#:�✓ TI V'� V`-''t/� `'�J� FROM To DIAn� I THICIWEss '. :�Y7.2n' T•T.
List all applicable well constructionpe its'(r.e.WC,Cow*,State,Parlance,etc.)- M ft• in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17,"SCREEN',:-:.: - ..;__ _ :,:. :.`.::•.ir.' :;.. .:=
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL .
Agricultural QMunicipal/Public ft ft in.!
gift
Geothermal(Heating/Cooling Supply) )r Residential Water Supply(single) ft ft
I Industrial/Commercial Residential Water Supply(shared) _
!Ini ation FROM TO _ •,MATERIAL - HwLACEMENTMETHOD&.4MOUNT
Non-Water Supply Well: 0 ft• 20 ft. hentonite , poured
Monitoring Recovery ft. ft.
J.Injection Well:
i A uifer Rechar e ft ft .
g J Cn-oundwater Remediation
�;�, :19:SAND/GRAVEL'PACK if a'llcabre
Aquifer Storage and Recovery nSalinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. fL
i Experimental Technology [3Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer :ZO.DRILLING.LOG'(attacti additi in'sl sheets necess"')';'�'= :`�
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soilfrock type rain size,etc
ft ID ft
4.Date Well(s)Completed: LZWell ID# (� ft d it
' vi, A ri,
5a.Well Location: o ft 146
ft4106
Qta,' l�l erS ft Q t w , t�
FFIcility�wner Name Facility M#(if applicable) t ft
ti Y 7J�� �(]I • ft ft
Physical Address,City,and Zip ft. ft p
(0 o`/1 I �9 21:REMARIfS - -:,
or I
County Parcel Identification No.(PIN)
' ariiv-.tSaN 11'th�
5b.Latitude and longitude in deaarees/minutes/seconds or decimal degrees: �.
.i Cr' rnr';i
(if well field,one lat/long is sufficient) 22 Cei.tifi /
77 3N '�S o 7 / CJ W
6.Is(are)the well(s) IPermanent or Oi Temporary Signa ofCert' ed Well Contractor Date
By signing this form,1 hereby certify fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or §No with 15A NCAC 02C.0100 or 154 NCAC 02C,0200 Well Construction Standards and that a
If this is a repair•,fill our known well construction uction irtformafion an explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �00 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths 1fdi,�erent(example-3@ 000'ry'and 2@100) construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use'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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r L[ construction to the following:
(Le.auger,rotary,cable,direct push,eta)
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&Iniectiori Wells: In addition to sending the form to
/1-p the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: (0 rir[ice 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 .F Revised 2 22 2016
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