GW1-2022-10715_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information: r
14:.WATER ZONES
Well CoWell Co�a FROM TO DESCRIPTION
co V � ft ft I,
R ft
NC Well Contractor Certification Nrmbet 15 OVMM- :eASING,(foc zh:d i-cased�vel>s)OR I rf a'licable)'
Morgan Well &Pump, Inc. : FROM TO DIAAS71M THICIfi A MATERIAL
+1 ft ft Gila/ in' sd21 Pvc
Company Name " ,,N> ..�• _.:..:'
))) I6 BIZ CASING OR'•TQBIIVG. 'eottierraal cl6sed lod
2.Well Construction Permit#: LSRI FROM To DrAMETER THICKNESS n2aTERTAL
List all applicable well construction permits'(i.e.UIC,County State,Variance,etc)• ft ft in.
ft ft h•
3.Well Use(check well use):
Water Supply Well: FROM TO DWNETER SLOT SIZE .~THICKNESS MATERIAL.
!Agricultural CiMunicipal/Public ft ft in-
'Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft fL �•
7ndustna'�1 Commercial Residential Water Supply(shared) ;:-:r e :. .:.•-_..:. ••.:.: _
S lui ation FROM TO MATERIAL Fd0L-4CEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
'Monitoring [3Recovery ft. ft-
Injection
Well: ft
Aquifer Recharge Groundwater Remediation
�, :.19:St111D/GRAVEL'PACK tf a'lirabTe :_.":::^:.::
`Aquifer Storage and Recovery F__'PSalinity Barrier FROM TO MATERIAL EMPLACEMENT'METHOD
Aquifer Test QlStorruwater Drainage ft ft
!Experimental Technology Subsidence Control & ft
Geothermal(Closed Loop) [ITracer :20.DRU=GLOG'(atti6badditiunalsheed-ffieces
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rockty s z�etc)
ft ft.
4.Date Well(s)Completed: 1_Z D ell ID# d• ft ft /` d
Sa Well Location: f
ft 00 fte ft ft
AU U. po—
Fri ity/Own Name Facility M#(if applicable) ft ft `-
ft ft --�.�.�:�ie.a 5 ,.V L
Physical Address,City,and Zip ft ft F202
�_10 wor\ '21e12FMARTCR" _ - _ - -'.*.'_.-:.:.:�::�;i.:'.;.i•::. r:
County PatcelIdentificationNo.(PIN) In
forYFi": :�tr t';_'�'s• :� l t ,l
e. dam' tie.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one UV101 g is sufficient) 22.Certifi o :
iz&. 681 N .�28� W - 1-22
6.Is(are)the well(s) Permauent or Temporary Sig`na f Contractor Date
By signing this form,I hereby m*fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 1�To with 15A NCAC 02C.0100 or 15A NCAC 02C.02o0 YPen Construction Standards and that a
If this is a repair fiII out/mown well construction iniformarion d explain the nature of the copy ofthi6 record has beenprovided to the well owner.
repair under#21 remarks section or on the back 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'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft.) 242. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths if difarew(example 3 D((D..'--ma�id 2Qa 100� construction to the following.
10.Static water level below top of casing: �y (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY VVELL&ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
air pressure 24c.For Water SuppIy&Iniection Wells: In addition to sending the form to
13a Yield(gpm) Method of test
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount.• 01 completion of well construction to the county health department of the county
where constructed
Revised 2 22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources