GW1-2022-10143_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only.
1.WeR Contractor Information_
QCCeil jause, •14..WA1'ERZONES C. ' .': .' ..•!e ....•'
FR Well Contractor Name - ft. TO � DESCRIPTION
. 0" A - ft ft _
NC Well Contractor Certification Number l
15:OU�E•R>L9�S G,(fa"rmnitY=u:aseafVP ORL7HELt(�
Morgan Well & Pump, Inc. : FROM TO' DIAhIIETERI THI(Si TOSS MATERL4•L
+1 61161 sd21 pvc
Company Name ^ 1495
r(n-(J, 16"II II�R C9SING OR•TIIBING: 'eotTiermal cIo's@d 106
2.Well Construction Permit#: FROM To DIAMME t:'. TBICKN%SS . MATExrAL
List all applicable well canstruciionpm7rd4r'(La UIC,Cwadv,State,Ymiw=erc,} ft' ft. in.
3.Well Use(check well use): ft. ft
Water Supply Well: 1'z SCREEN'.>:..- _- .'•�',�•'_-- .�::';t:.• �� ..';.•�::`�:-�- -t:,'-.:.•.:_`•`
FROM TO DIAMErER 6LOT SIZE -TffiCiQiESS-. MATERIAL.••
Agricultural i Municipal/Public ft ft n•
fTt
Geothermal(Heating/Cooling Supply)- Residential Water Supply(ogle) ft ft
I hidustial/Commercial !Residential Water Supply(shared :•`-••.• ;;:.::.`:: -•_::•:_'` ':.
"GROUT-.c. :, _'•:`.: i. _.
thii ation FROM TO MATERIAL FADL CEMLNTMETHOD&AMODNT
Non-Water Supply Well: 0 M 20 f bentonite poured
s Monitoring DRecovery ft ft
Injection Well: ft
J Aquifer Recharge of Groundwater Remediation
.19:SAND/GRAVEL'PACg rf a 5lickbre " :::• :: ':':''; ;:.
Aquifer Storage andRecovemyISalin:tyBanier FROM TO MATER7AI ErOLACEMENTMETHOD
Aquifer Test DStormwater Drainage ft' ft.
i Experimental Technology DSubsidence Control ft ft
i Geothermal(Closed Loop) 1ITracei :20.T7RIILf1\'GLOG'(aftkcli additiaual slieets�fnecess 7'::"'> -€'•.` 'i
Geothermal(Ileating/Cooling Retum) i Other(explain under#21 ) FROM TO fL I DESCRIPTION( lors hardness soWmektppes grain raps etc.)
,L I
4.Date Wel(s)Completed: P� Well ID# b. t ft.
5a W Lo � ft.
—`g ?l 1k� !/ ft. ft. /1
Facr7rty//� Nam Facility IDfapplicable) ft. ft.
/q.
tl(ideJ� C ft ft. —NOV 1 Ad dress,City,and Zip /` ft ft O��
1(�y �S� �S` 6cow :aI:7l rauus— - - r.r Unk
-
County ParcelS6IdentiEcationNo.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell eld one IaUlong is sufficient) 22.Certification: t
w .D� 7
6.Is(are)the wells) A Permanent or !_9'Temporary Signature of Certified Well Contractor i •Date
By signing this form,.1 herekv rer*that the wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or' j No with 15A NCr1C 02C.0100 or 15A NC.AC 02C.02oo Well Const=don Standards and that a
If flits is a repair,fill out known weD construction information and esphdn the natm•e ofthe -PY ofthis record has been provided to the well owner.
repair under 421 remar6s section or on the bark 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 I GW-1 is needed Indicate TOTAL NUMBER'ofwells construction details. You may also attach additional pages if necessary.
dulled: - Y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Prdifermf(ermnple-3Q200'n 1@ f 00� construction to the following.
10.Static water level below top of rasing: ,lj (ft-) Division of Water Resources,Information Processing Unit,
,Ifwoter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form witbin 30 days of completion of well
12.Well construction method: O r L[ construction to the following.
(Le.auger;rotary,cable,dnreetpush,etc.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
i
132-Yield Lapin) Method of test: air pressure 24c.For Water SuppIy&Injection Wells: In addition to sending the form to
Ithe address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type- A C�iACA ar Amount: 6 bA, completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of water Resources Revised 2-22 2016
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