GW1-2022-10720_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
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FROM TO DESCRIPTION
well�Contractor ameft-
ft
NC Well Contractor Certification Number
'15:OUP'ER--GASTNG,(fo�i•mnlfi-rased9relLs ORL-II`� ifa'licahle'1:�::`.:.;:•'•
Morgan Well &Pump, Inc. mom TO' DIAMETER THIClf1i'SSS MATERIAL
+1 fL ft 61/8/ m' sdr21 pvc
Company Name -e
1
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6 IIVNER G OR:•TUBING• otlier'ma1 clb'seddou
2.Well Construction Permit#: FROM TO DIAMETER THIGT4�TESS MATERIAL
List all applicable well construction permits'(1.e.iIIC,Cotnnv,State,Variance,etc), ft ft. m•
3.Well Use(check well use): ft ft. m ,
17."SC:REEN•.:•..
Water Supply <. `::. .`• .._`:.:.-:•;:'l:. ;: „'::•:..:;. . .:.:. ::.
Well: FROM TO DIAMETER : SLOT SIZE THTCKMS MATERIAL.
Agricultural EDMunicipal/Public ft. ft �•.
Geothermal(Iieating/Cooling Supply) Residential Water Supply(single) ft ft �•
I TndustnarTl Commercial i Residential Water Supply(shared) :__:, •.:...::-'1: •:,. : ':
I Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&-AMU IINT
Non-Water Supply Well: 0 ft. 20 ft- ben'nite poured
Monitoring Recovery ft ft.
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
.19:SAND/GRAVEL if a'lica6le
'Aquifer Storage and Recovery Salinity B awer •FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test Stormwater Drainage ft ft.
I Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OITracer :20.3)RMIMiG.LOG'(atti6'sdditfdli sheetiifaccess"
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,safurock ty In s ze etc
ft V ft 4.Date Well(s)Completed: Well ID# ft ft T U
iA
Sa.Well
-Location: ft "^r
Facility/Owner Name Facility ID#(ifapplicable) ft ft a `i.4 L"..
2 ft ft .-
-ro_ ft & l_
Physical A�ddre ,City,and Zip
�l/�A/ °2Ii•RIZMARICR'- _ _:f- _ ...:.7—
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Ifield,one]at/14 is sufficient) 22.Cer
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6.Is(are)the well(s) Permanent or OTemporary Signat&CoYCertif3eeW dUtraCtOf Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or �ititYo with 15A NCAC 02C.0100 or 15A NCAC:02C.0200 Well Construction Standards and that a
If this is a repair,fR out known well construction Ldformafion an�ezplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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 1 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-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multr'ple wells list all depths ifdljfereat(example-3(200'old 1@100D construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casino 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rQtpir L I
construction to the following:
(Le.auger,rotary,cable,directpusla,etc.) Ji
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEI LS.ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: �\n"�i Amount �� _ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016