GW1-2023-01710_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
/Contractor Information:
-f —Fo. 1 14.WATER ZONES
Well Contractor Name FROM LTO DESCRIPTION
ft. ft.
T`�e — � ft. ft.NC Well Contractor Certification Number 15.OUTER CASING for multi-med wells OR LINER if a licable
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. a ft. 61/8 in' sdr2l pvc
Company Name
/;n �� 16.INNER CASING OR T[IBING(geothermal closed400
2.Well Construction Permit#: `�lI 1 FROM TO DIAMETER THICKNESS MATERUL
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: 17.SCREEN
FROM TO DIAMETER SLOT SUF THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(colo,hardness,soil/rock C rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) ,c7 f. q< ft. i2e 4 1
4.Date Well(s)Completed: Well 1D# V ft. b ft.
5a.Well Location: 0 ft. L ft.
ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2
D � � M CAI' p ft. ft
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) tT 22.Certification:
NC00 W �/-
6.Is(are)the well(s)Ox Permanent or Temporary Siglapee orCftdheMel1 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: [3Yes or x®No with 15A NCAC 02C.0100 or 15A NCAC 01C.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: Z 60 (ft-) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 tQt 200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wuter level is above casing,use-+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection type: chlorine
the address(es) above, also submit one copy of this form within 30 days of
Amount: 1 D completion of well construction to the county health department of the county
where constructed.
For.::(i%k-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016