GW1-2022-10733_Well Construction - GW1_20221208

WEJ,L CONSTRUCTION RECORD (GW-1)- 7Prntemal Use Only:
1.Well Contractor)Information:
la:.WATERZONES
FROM TO DESCRIPTION
Well Contra /Name ft.
NC ell Contractor Certification Number 15;pR,egSING,(fo"r mnlfi-rased wells)OR ZR(if - licahle)'1 :: '• •=
Morgan Well &Pump, Inc. = FROM TO' DIAMETER' THICFfiVFSS MATERTA7
+1 ft. ft. 6Ila/ in- sdr11 PVC
Company Name
99 y� (� 16.`Il�II`IER CAS'Il�TG 012•TCIBING'•eotlier'ma1•clo'sed ltio
2.Well Construction Permit#: i nW �2�`�� FROM To DIAMETER in.
MAT PJAL
List all applicable well construction permits'rLe.UIC,County,Stale,Variance,etc)• ft ft in.
ft. ft. in.
3.Well Use(check well use):
17:SCREEN.:
Water Supply -:::. .'�.;'.:•_•.: :,:;:` -',::-;,.r :.::.;::a{..:T.:.•. .:
Well: FROM TO DIAMETER SLOT SIZE THICKNESS 14IATERIAL.
i Agricultural DMunicipal/Public ft ft in.
I Geothermal(lieating/Cooling Supply) JIResidential Water Supply(single) ft ft. In.
TiindustilaUCommercial J Residential Water Supply(shared) ;19:GROUT::•, :; ' :' ; ':'::':•':=`''s:;:-' '';:'::: ::•:':' "-' `- '; ';
E irrigation FROM TO I MATERIAL Iti PI&CEMENTMMTHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft- bmionite- poured
'•Monitoring DRecovery ft. ft
lGeothermal
jection Well: ft ft
Aquifer Recharge Groundwater Remediation _:: '•:: .:r•-: :•,'
y79:SgND/GRA.VFL'PACK if a'•licabl1e
Aquifer Storage and Recovery nSalinityBarrier FROM TO MATERIAL. EMYLACEMENTTV=OD
Aquifer Test E3&ormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer :20.'DRILLING.LOG•(attiili'additional sWietsjf necess"-)'
(Heating/Cooling Return) J Other(explain under#21 Remarks) FRoM Ft TO
ft. DESCRIPTION(color,hardness soil!ock type in sue,ere)
`�� d OSIN
4.Date Well(s)Completed: ZZWell ID# ft ft.
5a.Well Location: v
^ —( ® ft ft
er
Facili y/O11wnnner Name Facility M#(if applicable) R ft
ire M f
�C Q�e•� �a`-I t a ��,..�,.,.��
Physical Address,City,and Zip ft ft nF r 1
` ) :21:F.EDLaRUR=:?- `:f`--.:;,;`..:.:�:`S:�`�-•�:-,^='t,-;l.:``-.: ;_�;.:':
ljntt
County Parcel Identification No.(PIN) in vlrril Ja-7' i...+i>yl•
I
5b.Latitude and long tude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifi lion:
S�),q lg 77 -N gl- 106 q 3 W K) - 11�Zrt,
6.Is(are)the well(s) 'ernmanent or Q1Temporary
Signa f ert' ed Well Contractor Date
By signing this form,I hereby cerY fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or, I No with 1SA NCAC 02C.0100 or 154 NCAC 02C-.0200 Mell Construction Standards and that a
If this is a repair;fill out known well consk action iriformatio and explain the nature afthe copy ofthis 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 1 GW-1 is needed. Indicate TOTAL NUMBER'of weJls construction details. You may also attach additional pages if necessary.
drilled: -200 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 multiple wells list all depths if di fferent(example-33@200 and 2@100) construction to the following
10.Static water level below top of casing: / a (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.
24b.For Infection 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: � �L� construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Inj ection Control Program,
FOR WATER SUPPLY'WELLS40NLY: 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
the address(es) 'above, also submit;one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to ,the county health department of the county
where constructed_ 1
Revised 2 22 21116
Form OW-1 North Carolina Department ofEnviromnental Quality-Division of WaterResources