GW1-2022-10233_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Chris Morgan f4 waTERZONEss
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3572-A 7�
ft. ft.
NC Well Contractor Certification Number 15;OUTER'CAS1NGfoT"mrilh�asedwells''ORLINERila licable
Morgan Well & Pump, INC FROM TO_ DIAMETER ! THICKNESS MATERIAL
ft. �(,+ ft. f in.
Company Name
r �j 16zINNER CASING:OlYTUBING "eotheriial`closeddoii'' •-"�
2.Well Construction Permit#: G�WZ�� O72J9 FROM TO DIAMETER T THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,Couno,,State, Variance,etc) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
17 SG MEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
-JIGeothermal(Heating/Cooling Supply) 0IRe dential Water Supply(single) ft. ft m
_ Industrial/Commercial esidential Water Supply(shared) 18.rGROUT a%
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. bentonite poured
nMonitoring ®Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
`:SAND%GRe1yEL'PACICtifa"`licatile
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D'Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20:DRILLINGL'OG:(atfach additional sheets=if'necess"'
FROM TO DESCRIP.TTON(color,hardness,soil/rock type, rain size,etc.)
_ Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) v, ft. 0 ft.
4.Date Well(s)Completed: 1644 Z2 Well ID# �. ' ft. -75 fL SrVWK
Sa.Well Location:
-76
ft. 10 ft.
r�
TX lyc,s
Facility/Owner Name Facility ID#(if applicable)
6ac'JC S at- LLT.. Q
ft. ft.
Physical Address,City,and Zip
w -
14k&//1.
County Parcel Identification No.(PIN)
GWQiES10G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.CItion:
35.5073 N —'71•0575 W
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certi ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided 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 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 multiple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 36 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: r 24c.For Water Supply&Iniection 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:
chlorine Amount: 7o7, 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 2-22-2016