GW1-2023-01525_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ZONES 5'y: :' ;: :? '. ..::. :"::s i>:: ::::;;.'V...:::s: :
Chris Morgan la:;VifATEIL. .
FROM TO DESCRIPTION •
Well Contractor Name /Z6,-ft. 74 ft
3572-A
ft. ft .
NC Well Contractor Certification Number
LS:'O.FITERCASIN.(focdiui..case°d ell ©RLINER(ifap licableERIA':r;::::;it• ;;;`:
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. S0 ft. In.
Company Name a7
'ii6 INN RCASINGORrI.OBING(teethe ranatelosed3aop)Y;::_>:z:: :;::: c. :i< °:[::
2.Well Construction Permit#: g 7Z 1/`7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water.Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in. •
Geothermal(Heating/Cooling Supply) OPediclential Water Supply(single) it ft. in
Industrial/Commercial 0Residential Water Supply(shared) Gkt ............:..........--..--...:... :: -........
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD is AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring . DRecovery ft. ft. .
Injection Well: ft, ft
Aquifer Recharge 0 Groundwater Remediation
i:'19F.SAND/GR'AAVEiL PACT((f applicable). :.`.:::::
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology riSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer i(LnitIILLIl+TG'LOG'(attach'additiouai Sheet*ifnetessary)' ::?-::��:::?; :i'..,=sa::::>;; ::
FROM TO . DESCRIPTION ol(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)2 Other(explain under#21 Remarks) Q ft (,�0 ft �YOWdI l�/Q��
4.Date Well(s)Completed: 1-2 23 Well ID# Li J ft. 20, ft‘ 6vCi O2KAV4' 'C
ft
5a.Well Location: •
ft
LAW 6l 6w�l ft. ft.
Facility
y//ownerName Facility ID#(if applicable) ft, ft A. ..Z,., > —-r L = t !-. •
SW` L414 r 1 C Or. ft. ft _ FEB 1 ZD?3
Physical Address,City,and Zip ft. ft.
County Parcel Identificatio No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
N W O_____1._ ... ..........22.
1-23-23
6.Is(are)the well(s)JPermanent or IDTemporary Signature ofCerti,e 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: T)Yes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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
rnnstruction,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: 'ZOO (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: 30 (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: Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) to Method of test: /-1 j r 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: chlorine Amount: 7Qt_ completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016