GW1-2022-09253_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-Il_ For Internal Use Only,.
1.well Contractor Information: r
old 14.:dATER ZONES;. '
S inn Vl FR TO .DESCRIPTION. .
Well Contractor_rN— 3�H• `� ft.
35�2-P� ft ft
15:OUTER CASINfs",(fo"r multi casedwells)b7tL'II (ff'_.lirayle)'-
NC Well Contactor Certification Number ,\ DIAMETER t �Q�*E,SS MATERIAL
FROM TO'
Morgan Well &PUMP, Inc. +1 M ft 61/8/ in'. sdm Pvc
Company Name 16 AIR CASIING 01t•TQBIIIG.
eothermal'r1o'sedloo' '.'•."'a' r:%''
N�� FROM TO D7At "rER TSICI�TF�SS . . MATERIAL
2.Well Construction Permit#: j�j ft ft 'n
List all applicable well construction permits(i e.UIC,COIarN,State,Ym7mice,etc, ft in
3.Well Use(check well use): .,:•`_ . ,,::; .::-i:•_`::,• ,
17,SCREEA7',=:..= :` ,•
Water Supply Wen: FxoM To DIAMETER :SLOT SIZE r?ITCTSS MATERIAL.
���--- unicipPic ft ft
Agricultural ��� / m
1 esidential Water Supply{single) ft ft in
Geothermal(Heating/Pooling Supp y) � _ .:. •.::_• :..,.;_ ,r..=..::--,�•-:.'•.
dus Commercial Residential Water Supply(shared) ;%Ap�� *�- TAT M&?TACEMENTMETHOD&3MOUNT
FROM TO
Imri ation - 0 ft- 20 ft bentonite• - poured
Non-Water Supply Well:
Monitoring
Recovery t ft
Injection Wen: ft ft �._,: .•-.
Aquifer Recharge Groundwater Remediaiion ,.79:S�yD/GRAVEL'Pd CS>f a"Iirable
S Bawer FROM T 0 MATERIAL ::'FSMPLACEaI�NT METHOD
Aquifer Storage and Recovery al,nity ft
Aquifer Test Stoimwater Drainage
Experimental Technology DSubsidence Control ft ft'
Geothermal(Closed Loop) OTracer FROM CSIPIG.I;OG'(afrachnFs�rToNN(m�nh��oillroek!y� g .- size,etc)
PCh-othemal
FROMro(Heating/Cooling Return) ,j Other(explain ender#21 Remarks) a It ft
C-fi Well ft ft
4.Date Well(s)Completed: .
ft (to ft _
5a.Well Location: ft ft _
— s T
Facility/Owner Name Facility ID (if applicable)
it ft.
ft-
ft
Physical Address,City,andZrP 2 -- '- ' _ .`�;�;3r,;ii1;:�::•i��- .:J .
�e �J •21e'R7i Nf6RTI.C" <i,. �-i. - ��� .
UkcA.-,
County Pa:celIdentificationNo.(PJN)
5b.Latitude and longitude in degi ees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22_C ratio
S N ��1, ?� w 7= Z2
Sift r of C Well Contractor Date
6.Is(are)the well(s) •Permnanent or Temporary that the weII(sJ was(were)constructed in accordance
By signing this form 1 herebv certify
7.Is this a repair to an existing well: Yes or ONO with 15A NCAC 02C.0100 or ISA NCAC 101C•.0200 Well Constnuctian Standards and that°
If this is a repair,fill out known well construction itiformation and explain the narta e of the copy of this record has been provided to Zhe will owner.
repair under 421 remarks section or on the bark of thisform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (ft-) 24a. For All Wells• Submit this form within 30 days of completion of well
For multiple wells list all depths 1f different(example-3@200'and 2@100D construction to the following.
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
Ifwater level is above casino use
11.BorehoIe diameter: 6 (�•) ) 24b.For Iniection Wells: In addition to s the foss to the address in well
above,also submit one copy Of tis h 'formwi thin thin 30 days of completion of weell 12.Well construction method: CO construction to the following:
(ie.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground ANC ion 9ontro Program,
1636
F13b.
ATER SUPPLY WELLS,ONLY: 1636 Mail Service Center,Raleigh,
d(gpm) b O Method of test air pressure 24c For Water Sanely&iniectiol Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
nfection type: �Y�V�ci Amount: 12117 . completion of well construction to;the county health department of the county
where constructed_
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmentai Quality-Division of Water Resources j
I .
j