GW1-2022-10150_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Infazwatiom. /}
QCCe�� C�QU�I� .14:.WATERZ0NE3
Well Contractor Name TO IP DESCRTION
�J5®� 4
NC Well Contractor Certification Number I.
15:OU�E -CASING,(fo"rmnlfi;' sedWMs)OItMURCif'a
Morgan Well &Pump, Inc. FROM O' DIAMETER I THICSIY'ESS IMATEPTAL
Company Name �w +1 ft ft- 61/s/ [in•, sdf21 pvc
'.`J�' lt':71�ER CE.S'ING OR•TIIBl1VG. 'eotiiermalcIo'sed-loo' i.
2.Well Construction Permit#: FROM To DIAMETERi THICENEss MATERIAL
Lint all applicablewel7constructionpermits(le.UIC,Coaadv State,Vmianm etcf ft' ft in
3.Well Use(check wen use): ft. ft. in
Water Supply Well: 1 SCREEN', :. `::. .`�• •._.`_::'-. �,::;:, . . :
FROM TO DL4METER '.SLOT= 'I.'A'ICKNFSS MATERIAL.
Agricultural UMunicipa]/Public ft ft in.
Geothermal(Heating/CoOling Supply)- B IResidential Water Supply(single) ft ft in.
I Industrial/Commercial Residential Water Supply(shared)
Ill atiOn FROM TO MATERIAL;-.• EMPL-4CEMLNTMETHOD&AMOUNT
Non-Water Supply WeIl: o ft 20 ft bentanite poured
Monitoring Recovery ft ft
Injection WeIl:
—Aquifer Recharge CnoundwaterRemediation it ft
;:19:SAND/GRAVEL'PACK tit "livable rm�
AquiferStorage and Recovery DEalinity Barrier FROM TO MATERIALENT INS OD
JaGAquifer Test DStomiwater Drainage R ft c UMt
Experimental Technology Subsidence Control eothermal(ClodLoop) QlTracer :Z0.DR1LLii�'GSOG'(zttachadditiorisIsbeetssfnecess 7°:: .othermal(fieating/Cooling Rearm) Other(explain under r21 ) FROM TO DESCRIPTION(color,hardness soil/mck type grain s ze etc)
ft b ft
4.Date Well(s)Completed; S ' Well ID# C-) f, 3� ft �v`.ar�
Sa.Well Location: ./ ft. ZO it 7( ,• `
ft ft �M1si<C
Fac /O n rName w Facility ID#(ifapplicable) ft ft.
� S 72� ft ft
Physical Address,City,and Zip
ft ft
coountyy`//TV/l4 Parcel Identification No.(PIN)
5b.Latitude and longitude in de.arees/minutes/Seconds or decimal degrees:
ff)fa fold,_y/,�L�� cient) W 22_Certification:
N
6.Is(are)the well(s)AP
ell(s) Permanent or OTemporary Signature of Certified Well Contractor Date
�� By signing this form,I hereby cerYfy that the we11(s)was(were)constructed in accordance
7.Is this a repair to an e.idsdn.a well: Dyes or° I No with 111 NUC 02C.0100 or I5A NCAC 02C•:0200 Ppell Construction Standards and that a
If this is a repair,fill out(mown well construction i6formation and explain the natw•e ofthe copy ofthii record has been provided to the well owner.
repair under*21 remarks section or on the bark of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or C)osed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled.--' " I SUBMITTAL INSTRUCTIONS
9-Total well depth below land surface: w (ft) 24a. For All Wells: Submit this form,within 30 days of completion of well
For multiple welly list all depths frdifferent(example-3 t@r 200'and 2@1000x0� construction to the following.
10.Static water Ievel below top of casing: V A) Division of Water Resources,Information Processing Unit
Ifwafer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to;sending the form to the address in 24a
12.Well construction method: Q �L� above, also submit one copy of this fomr'within 30 days of completion of well
construction to the follov&g:
(Le.anger,rotary,cable,directpuslr,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,IJhderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
- 4
13a•Yield(gpm) Method of test: air pressure t g
P 24c.For Water SupuIv&injection WeIIs: In addition to sending the form to
o the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:�C'L-10 ai - Amount: D'L completion of well construction to the county health department of the county
where constructed. 4
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016