GW1-2022-10204_Well Construction - GW1_20221111

Vi1ELL CONSTRUCTION RECORD (GW-1) I For Internal Use Only:
1.Well Contractor Information-
�Ac�e}� 4us e •1a:.97ATER ZONES:'. - �•.l..'.�:.��::''- .
FROM I TO DESCRIPTION
Wall
lJContractor Name � NMI.
it � ft
{J Y tt ft
NC Well Contactor Certification Number
15:OU�EIt:a"ING',(fo"r mnlff-rased was)I0 2 T E)2 C�a'livable)'
Morgan Well&Pump, Inc. FROM TO' DIAMIr ER I T� s
+1 ft 611a1 sdr21 pvc
Company Name 121 A ,,�� j.:.:'c-'_
J(/� ld 7rII C 4SING OR•TUBING: eotliermal closed hod
2.Well Construction Permit#: FROM TO DIAMETER I TfficRrlEss MATERIAL
Lis!all applir�ble well ronsiruciion penrdir'(L e.LUC,Caauv,SmI4 P r anc,eta} M fL in.
I Well Use(check well use): m _
il
ater Supply Well' PROM TO DIAMETER~ SLOT SIZE ^TffiCKTESS MATERIAL.
Agricultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply)' 5Resideffdal Water Supply(single) ft in.
Industrial/Commercial Z3Residential Water Supply(shared) GROUT::.. - - - -
Isi atlon FROM TO rvid Ti RTBT. EMPI4 3
Non-Water Supply WeII: 0 ft- 20 fc bentanite• poured r
Monitoring ORecovery ft ft2022-
Injection Well: ft ft ��P
Aquifer Recharge KI Groundwater Remediation
;.19:SAND/GRAVELT.&Cg if a"hirable
Aquifer Storage and Recovery EISalinity Barrier FROM To MATERIAL E PLACFAMNT 1AETWD
i Aquifer Test Q18tormwater Drainage ft ft
i Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) 1ITracer :20.DRU,=NGSOG'(attacti additiottalsZleets
I ) FROM TO DESCRIPTION(ralo,hardness,soil/rock type,grau5 size,etc)
Geothermal(Heating/Cooling Retum) J Other(explain under#21
4.Date Well(s)Completed �r�OL WeIl TD#/ ft ft
Sa.We Location: D ft
L ft. ft � 0�••
ft it I '
Fit0wner Nam Facility ID4(if applicable)
d O��'CCI�,r(, a!(►'�S i� /+zev�y ft ft
Physical ddress,City,and Zip � �
w
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
5_1(rfwe fiel, one N _` W 22.Certification: Z�
6.Is(are)the well(s) Permaneut or OTemporary Signature of Certified Well Contactor Date
By signing this form,I l:erelry certiYy that the weII(sJ was(were)constructed in accordance
7.Is this a repair to an e�dsting welL• ©Yes or j4No with 15A NCAC 02C.0100 or 15ANCAC 02C10200 WeII Conshvction Stands ds and that a
If this is a repair,JIB out known weE construc ion information and explain the nature of Me copy of this record has beai provided to the well owner.
repair under 421 remarks section or on the back of this form
• 23.Site diagram or additional well details:
S.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 1 GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: ' 9 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit,this farm;within 30 days of completion of well
For multiple wells list all depths ifdIerent(ezmnple-3 a 00'aannd 22@100) construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwoter level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
II.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to isendmg the form to the address in 24a
f above, also submit one copy of this faimtwithin 30 days of completion of well
12.Wen construction method: LA r L` construction to the following:
(Le,auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
r� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type C'i,101 os Amount: 10 completion of well construction to the county health department of the county
where constructed
i
Revised 2 72 2016
Form GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources