GW1-2022-09255_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-
For Internal Use Only.
1.Well Contractor Information: J r
ATERZONES •.: .:':.
FROM TO •DESCRIPT1014
ft ft f
Well Contr,e=Name
f
5a t �5
,572— ,(fo"rmniti ra@edvtalS)O 2
?
rCerfificarionN>•tmbet '15:OUTER=' DIAMETER t TSICIQIESS MATERIAL
NC Well Conliacfo l FROM TO'
Inc. ft. ft 611B1 sdr21 pvc
Morgan Well &Pump, +1 . - _,.::.�="�' :•:::•'.
16`IIB CYsSIIQG OB.TUBI1•TG. 'eotfiermal� �S MATERIAL
Company Name FROM TO DIAMETER
2.Well Construction Permit#: ft
consd uciion permits(ie UIC,CourrN,State Ymzanae,etc) in-
List all applicable well
3.Wen Use(check Well use): 17_SCREEN,r.•c`- D SLOT SIZE• •THICIOZESS MATERIAL.'.
1 Well: FROM TO
Water Supp y. ft
k Agricultural �I Municipal/Public
in.
Residential Water Supply(single) ft -
GeDthMmal(Heating/Cooling SupPl y) _._•:r ... - __.>.-. - .`
i Residential Water Supply(shared) g'GF2DgT' " :. MATe—T EMpL4CEMF�TMET$OD&AMOUNT
I ustn Commercial — FROM TO
Isi .on 2D ft bentonite, poured
D
Non-Water Supply Well: M ft
Monitoring Recovery ft ft
InjectionWell: jicable :.::_'':: . .:'.=,=':.'•.:.•:.
Aquifer Recharge I Groundwater Remediation �:ezxn/GgA�rES PACg>f ' " ALA =,y�rHOn
FROM TO MA'TR'—TAT.
'Aquifer Storage and Recovery �ISalinity Easier ft ft .
Aquifer Test DStormwater Drainage ft , :•:
ft
Experimental Technology oSubsidence Control
GLOG.(. ner2s 7' =:•i: etc)..:
2D.tiR71,Za' attach-addihdnaI sheetsjf �'
Geothm eral(Closed Loop) DTracer FROM TO DE SCRIPTION
(ealor,hardnes,soil/rock ty a grain s za
Geothermal(Heating/Cooling Return) �Other( lain under#21 Remarks) ft ifS ft
ft'J ft VrJCN�
4.Date Well(s)Completed: Well ID# l ft
6 g _
5Aa'.Well Location:
ft ft
/11 nut r1C�h t 1�3an dt ftft
''r.
s Facility IDN(if applicable)
Facility/Owner Name n ft ft
QZ65 ft -ft.
PbysicalAddress,City,and Zip =-j,L•.'RFMARXB7 _ _.1-
L PA
pa celldentificationNo.(PIN)
County
5b.Latitude and long trade in degrees/minutes/seconds or decimal degrees: 22 Certification'
(tf well field,one lat/long is sufficient)
5 S5�3 -N
, Date
Si a of ed Well Contractor
6.Is(are)the well(s) ermanent or Temporary By s o.Sg form I Iua-eby certify il+et the wel(s)was(were)constructed in accordance
wth 15J1 NCAC 02C.O1 D0 or ISA NCAC 02C.0200 WEE Cons'trucuon S�ndmds and�
a well: Yes or �"o coy ofthis record has been provided to the well owner.
- 7.Is this a repair to an existing © p
Ifthis is a repair,fill out known WED construction information and explmn the nature ofthe or additional well details'
repair under#21 remarks section or on the back of thisform 23•Site diagramto rovide additional Well site details or well
You may use the back of this page p es ifnecessa .
8.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same construction details. You may also attach additional pa a ry
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBERbf wells SUBMITTAL INSTRUCTIONS
drilled: (� of completion of well
9.Total well depth below land surface: l`J I r (ft-) 24a. For All Wells: Submit this form within 30 days P
wells list all depths ifdij�e ent(example-/3@200'an 2@200') construction to the following.
For multiple
10.Static water level beIow top of rasing: "l —(ft) Division of Water Resources,,Raleigh,
NC 27699 1617 Unit,
�36I7 Mail Service Center,Raleigh,
If water level is above casir:g,use
{ 24b.For Infection Wells: In addition to sending the form to the address in well
11,Borehole diameter: 6 (m') p of this form within 30 days of completion of well
I above,also submit one copy
construction to the following: .
12.Well construction method: 1� 1 Injection Control Program,
(Le.auger,rotary,cable,direct push,etc.) Under ound
Division of Water Resources, o NC 2 7699-1 63 6
i 1636 Ma11 Service Center,Raleigh, .
FOR WATER SUPPLY WELI_Q.ONLY: the form to
: cZ air pressure 24c.For Water Supply&Infection Wells: In addition to sendingOf
13a.Yield(gpm) J Method of test p the address(es) 'above, also submit one copy of this fomr within 30 days county
j, 2 completion of well construction to the county health dePar(meat of the county
13b.Disinfection type: �- �0�t' where constructed.
Revised 2 22-2016
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources