GW1-2022-10730_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD (GWW-I) For Internal Use Only: '
. I
1.Well Contractor information_
i QUse F FMATElt ZONES
FROM TO DESCRIPTIOO
N '•
Well contractor Name b ft V� ft I
�J5®� ft ft'
NC Well Contractor Certification Number I6:OUXERR:QASIN G,(formulixcasedwells)OR7 (�a Lcahle)'�:'::'•.•:'
Morgan Well &Pump, Inc. _ FROM TO' DiAmmm, TlHcr ss MA r�RTAr.
+1 ft ft Gila/ in sdr21 pvc
Company Name C U 1 Id"I1�NT ERCASIl�TGOR•TDSII�TG:''edtherrna�'clp'sed
l 1 1 FROM To DL4METSR
2.WellCDIIStSIIctiDIIPermit#: TffiCFfIIFSS MATER7hI
ft ft
list all applicable weII construction.Pm7dfs•(ie UIC,CDIZr*,State;Ymiance,eta)
br'
in.
3.WeJ1 Use(rheck well use): ;.,. .::;`. ?•-r;;•:.
Water Supply Well: FROM To DranWrr R': scoT srr rarcicNEss IYrATERTAT .
pludustrial/Commercial
Agricultural . OMunicipaUPublic ft. ft in.
Geothermal(Heatiag/Cooling Supply)- Residential Water Supply(single) ft ft in
Residential Water Supply(shared)
uPP Y ) ::Yg.GROUT::•' MA i FRTAT:- -�FAfp1,4CEMENTMETH0D&AMOUNT
Pirrigation FROM TO
Non-Water 1 Well: 0 ft 20 rz benton'rte• poured
DPP Y
Monitoring mmoveiy ft. ft
Injection Well: ft ft
JAquiferRecharge Kl Groundwater Remediation :xy.SAND/CRdVFyP1iCICIfa"lira5te
AZ..Stomge and Recovery 0salinity Banier FROM TO MATERTAL EMPLACEI�NT r14ETHOD
Aquifer Test DStormwater Drainage ft ft
r q .
1 Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :2o.DRII�IIdGSOG'(aitachddifionslsheetsifneces's"7:' `•-• eel
FROM TO DESCRIPTION(wIor,hardness,soil/rock type,e
I Geothermal(Heating/CoolingRetum) Other(explainunderr21 arks) ft ft ,
4.Date Well(s)Completed:I —ZZ-Z1 Well ID# ft b ft
ft ft Gv,c� S!ro�. .
Sa,Well Location: ! V
ft it
12(o CL
== Facility/OwnerName Facility ID0(ifapplicable) °
or
k �� D U.
eA vet' y �
ft ft
Physical Address,City,and Zip 9903
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County PatcelIdentificationNo.(PI fflii�iir:; �" =F2�
ri3tZly�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one latanng is sufficient) 22.Certification:
N yogZ �uover�S�' 22 &zZ
Sigiatare of Certified Well Contractor Date
6.Is(are)the weIl(s) Permanent or Temporary
ec� bb By signing this form,I berebv cw*yy that the wag($)was(were)consn ucled in accordance
with ISA NCAC 02C.010D or ISANCAC 02C.0200 WEE ConstLucAon Standards and that a
7.Is this a repair to an existrng well: Dyes or° No copy ofthss record has been provided to the well owner.
If thus is a repair fill out known well contortion information and erplarn the naim a ofthe
repair under 4121 remarks section or on Me bark of ibis form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
contraction,only 1 GW-1 is needed. Indicate TOTALNUNMER'ofwells
construction details. You may also attach additionalpages ifnecessary.
drilled: /f Q SUBMITTAL INSTRUCI'ION6
9.Total well depth below land surface: (� ( ) 24. For All Wells: Submit this form within 30 days of completion of well
For multiple wells llsf all depths rfdiffe-ew(example-3(a200'mu/2 00� construction to the following.
10.Static water level below top of casing' d (f£) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
.Ifwater level is above casino use"+"
Il.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In a ddition,to,sanding the foun to the address in 24a
1 } (r above, also submit one copy of this fo al within 30 days of.completion of well
12.Well construction method: o construction to the following:
[f.e.auger,rotary,cable,direetpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLX LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699 1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuppIv&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fb n within 30 days of
13b.Disinfection type C�o1 l✓ Amount: V completion of well construction to thei county health deparhnent of the county
where constructed.
Form GW-1 North Carolina Departrnent ofEnvironmental Quality-Division of Water Resources
Revised 2 22 2016
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