GW1-2022-09254_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-1) I For Internal Use Only: I
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I
I.Wen Contractor Informations
gCCe7l i Q V$e- 14:.D7ATER ZONES•.', :: '.
Well Contractor Name FROM TO DESCRIPTION .
gS50 y A (,{ ft ft
ft ft j
NC Well Contractor Certification Number
'15:OUTER:CASTNG,(focnulti
Morgan Well&Pump, Inc. FROM TO' DIAMETER 1 THICISNESS MATaarex•
Company Name +1 ftft- 1 6 Ila/ in'- sdr21 pvc
I ,J /� 16:'Dam CASING OR-TUBING: 'eottier�al
2.Well Construction Permit#: nyw/ 'c Im FROM To DIAMETER TBICENESS MATERIAL
List all applicable weHconstrucSonperrrms'(ie MC,Coum*State,Yartance,eta} ft ft in.
3.Well Use(check well use):
ft ft
. 17.-SCREEN',.:•�.: '•- :.+. -_ :.••..• i:. r..-•:_�::r----•.• ...:
Water Supply WeIL i,:ROM TO DIAMETER SLOT SIZE THICfGMS IrMATERIAL- ;
Agricultural rjMunicipaUTablic ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
I Industrial/Commercial E3Residexitial Water Supply(shared) ft. fL
GROUT..'.." "
:'In-i ation FROM TO MATERIAL E'1r.LACEMENTMET$OD&AMOIINT
Non-Water Supply Well: 0 ft 20 ft benton-rte poured
Monitoring DRecovery ft ft
I
jection Well: ft ftAquifer Recharge DGroundwaterRemediation
A offer Stom a and Reco !S Q g very OI ahnityBarer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStornawater Drainage ft ft.
&-perimental Technology Subsidence Control ft ft.
Geothermal(ClosedLoop) 1ITracerGeothermal(Heating/Cooling Ret im) Other(explain under#21 ) FROM T DESCRIPTION( or, artiness,soil/rock main sire,etc)
q ft. O ft
4.Date Well(s)Completed: 9-a�1'� Well ID# O . ft 3,- f, y�+�
5a.Well Loeration1C_(:_ ' - R Vs­o 7 J
C hc;!e1' 1-tw1su^ ft E57 fl- I JSJ
Facility/ wnerName Facility ID4(ifapplicable) ft ft
�2� Qlain� DO-
ft.Low {,
Physical Address,City,and Zip
/
W _
County Parcel Identification No.(PlN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(r<''well field,one]at/long is sufficient) 22.Certification:
35 'i2, N $I. Inlet
sue. Z1
6.Is(are)the well(s) Permanent or O±Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the'weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or 4j No with 154 NCAC 02C.0100 or I5,4 NCAC 02C,0100 FPell Construction Standards and that a
If this is a repair,JIIB out known well construction information and explain the natm•e ofthe copy ofthis record has been provided to the xe11 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 l 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 dayt of completion of well
For multiple wells bast all depths ifdifferent(example-3Q200'and 2@100� construction to the following.
10.Static water level below top of casing: �6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,',Raleigh,NC 27699-1617
11,BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the fors to the address in 24a
12.Well construction method L` above, also submit one copy of this foffi within 30 days of completion of well
(ie.auger,rotary,cable,duectpush,etc.) J
construction to the following: -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centex,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
o,t the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: C-LA01 a r Amount /" �- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparbnent ofEnvironmental Quality-Division of Water Resources - Revised 2 22 2016
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