GW1-2023-00520_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform fation_
QCC2� C1QUSe 14:.W4TERZ01\TES
FRO TO DFsCFJrT1ON
well ContractorName
AS50 ft l ft
NC well Contractor Certification Number 15:OD2�RG�dSIl�G,(fn'r mn7fi rageH Svr�s)ORLIlQER
Morgan Well&Pump, Inc. FROM TO' DIAMETER I TZECI FS8 MAT IUAL
I� (' +i ft it. 61/81 m sdr21 Pvc
Company Name V J�0 FR i r.,"s.._• ;':.•.. ;
4j�'A I /) tr OII'MTER CAS1tQG 012•TIIBIAIG:•eutfiermal'cIp'sed lnu
2.Well Construction Permit#: rV y FR°M T° DIAMETER TI�CT4ZE55 M4TERSAL
fL in.List all applicable weII construcdonpa nits' e.UIC,Comrty,&a1e Ymim:ce,etef
rL
ft ft. in.
3.Well Use(check well use): .-•�: - _-•.•. -
Water Supply We]L- VAOM TO DTAMECER~ SLOT SIZE `THICKNESS TYUTEBIAL•
Agricultural 01 MunicjpaUPublic ft ft
Geothermal(Heating/CoOling Supply)' Mesidential Water Supply(ogle) ft ft
I Industrial/Commercial DResidential Water Supply(shared} ;18:GROUT:;.":_ _ =-;::,:,aM =
!lnu ation FROM TO :-: MA rsuTdr. FDSpLSCEturFNTM=OD&AMOIINT
Non-Water Supply Well: o ft 20 fc benton'ite• poured
Monitoring Recovery ft ft.
Injection Well: ft ft
Aquifer Recharge Kt Groundwat=Remediation ^'
:.'19:SiiAiD/GEAVEL'PACg rf a"'tiraSle ":.:�::�:;:':.:._'-:'.•..:-,r'_;• '� '`.
!Aquifer Storage and Recovery MSalinityBasier 77TO�M.A_TERTAL L)RLACEMENTY=ODAquifer Test Dstoffiwater Drainage I E•'perimental Technology Subsidence Control
Geothermal(Closed Loop) ITracer :20.DItCLLIITGLOG'(altaeh'sd Tr onaT s]ieets u recess
FROM TO D�101NIrdnea,sail/rock e,grain s:-,etc)
Geothermal(Heating/CoolingRetim) 10ther(explainunder#21 arks) ft �4.Date Wells)Completed:` Well I N v
ft
52 WellLoration: ft ft-
Facility/OwnerNae Facility (i
ty ID# fapplicable)
m _
fL ft.
Physical Address,City,and
• �U i V�, -R`F'Mb.RTZR::Vic..;,.._ —_ _ _ ,��� t�!� _
County Parcel Identification No.(PIN) ^;1 t'; J t;i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �-
(tfwell fiel a lat/long is sufficient) 22.Certification:
3S, tfim N 91. Z3061 W
6.Is Care)the well(s) Permanent or OTemporary : Signature of Certified Well Contractor Date
By sio.-nvio this form,I hereby ceji thni the'weII(s)was(were)constructed in accordance
7.IS this a repair to an existing weII Dyes or° I No with 15A N42AC 02C.0100 or ISd NCAC 02d,0200 PPeII Consi:uction S m2dard m,s d that a
If tlda is a repair,fiR out(mown weD consb-uction Mformatfon and explain the natw•e ofthe COPY oftldr record has beat provided to the weU owner.
repair under 421 remark section or on the bark of fi&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 piovide additional well site details or well
contraction,only I GW-1 is needed. Indicate TOTAL NUNIBERbf wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total weII depth below land surface: (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells llst all depths if d ffi ki-ent(example-3 a 00'mu12@100) construction to the following.
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
,Ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
h.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: c 6"�( construction to the following
(r.e,anger,rotary,cable,directpwk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYIWELLS ONLY: 1636 Mail Service Center,;Raleigh,NC 276991636
13a-Yield(gpm) b Method of test air pressure 24c•For Water SuopIy&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this foan within 30 days of
13b-Disinfection type- !JC'jn01 ar Amount `b 2 completion of well construction to the county health department of the county
where constructed_
Revised2?22016
Form GW-1 North Carolina Department ofEnvirvnmentalQuality-DivisionofwaterResources
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