GW1-2022-09257_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Inform+ation_ /� JI
(�Cfe+l C ckQSe- •14:.WA.TERZONES<-,
Well Contractor Name - FROM TO DESCRIPTION
I
ft ft
NC Well Contactor Certification Number
� '15:O'O�EI�C�ASING.(fbcmnlfi-casedwePs)O�ZLII� if-a'licable)'s �":'.'-::••.`.:
Morgan Well&Pump, Inc. I hxnTERML
Company Name +1 ft 61/81 j sd21 pvc
�_ /'�� 16:"II�R CASING 01t•TOB]D}G: -eotliermal c1o'sed loo r
2.Well Construction Permit 4 b FROM To DIAMETER TffiCMgESS K&TERIAL
List all applicable weRconstruaonperndts'(Le-WC,County, State Ymiance etc} ft. ft �'
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: >Romr TO DIAMETER SLOT SIZE ^THICiOQESS r1YrATERL0.L.
_Agricultural rjMuaicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
I Industrial/Comrmmercial E3Resideatial Water Supply(shared) _ __,•}.-.,:.-.;.:`� -
'•Iai on FROM TO MATERIAL -: Edt2Pi.4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 R 20 ft- bentnn-tte poured
Monitoring ��.'Recovery ft ft
Injection Well: ft ft
Aquifer Rechargel CnoundwaterRemediation
19:ShND/GRAVEL•PACR ti a'6lirabl_e
fi Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACRMNT METHOD
I Aquifer Test Stormwater Drainage ft- ft.
I Experimental Technology OSubsidence Control ft ft. �.
Geothermal(Closed Loop) QlTracer :20.DRILLII�TG.T:,OG'(ztriicli-additionaisheets�faeces -7•`•.':'�%`'=sr,�=�•;'•-I:'s:• %' a"
I Geotheffial(Reating/Cooling Return) J Other(explain under#21 adcs) FROM TO DESCR PTION(color,hardness soiUrock type erniri
ft ft ,f 1^
Q .� 2?
4.Date Well(s)Completed: 1'u Z t Well ID# S• ft 15cp ft 66AU 1 e
/
Uft R5aWeIlLorafion: �(
ILI
JqZy PY.,A. L bC :
p ft ft S V CA—
Facility/Owner Name Facility lD#(ifapplicable) ft ft' v(_AA 3�Cve•aC.
Ito ft G ft
Physical Address,City,and Zip �]L Q/ ft ft.
/V BCC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lat/long is sufficient) 22.Certification:
�7Z y9Z N ILO.S'23G1
6.Is(are)the well(s) Permanent or Oi Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing,well: Yes or l No with 15ANUC 02C.0100 or 15ANCAC 02C.0200 WeR Construction Standards and that a
°
If this is a r•epau•,f91 out brown mR construction information and explain the nature ofthe copy ofihii record has been provided to the well owner.
repair under 421 remarks section or on the back 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 Geo, o only
I G or s needed.
I Geothermal Wells having the same construction details. You may also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER"of wells
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60 (ft-) 24a. For All Wells: Submit this form within 30 day§ of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2Qa 100D construction to the following.
10.Static water level below top of casing: SQ (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
i
11.BorehoIe diameter: 6 (in.) f 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method O r L1 above, also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct pusb,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
EDWisinfection
UPPLY ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
air pressure 24c.For Water Suuuly&Injection Wells: In addition to sending the form to
Method of test: g
ll the address(es) 'above, also submit one bopy of this form within 30 days of
type: `t-nol Of- Amo mty062 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparhnent ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016