GW1-2023-01802_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Co acto�o�on:
14.WATER ZONES
FROM TO DESCRIPTION
Well ontractor ame
342z..-Aft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM 1 . DIAMETER THICKNESS MATERIAL
ft. <7ft. 61/8 in' sdr21 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it:
3 6r15 gti 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: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultural 0Municipal/Public ft ft in.
0 Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
)Irrigation 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 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ID Aquifer Test D Stormwater Drainage ft. ft.
In Experimental Technology EtSubsidence Control ft. ft.
(Geothermal(Closed Loop) DTracer 1 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks)
a ft. 4S ft. rj A ±
4.Date Well(s)Completed:( fi.ô
lag Well ID# �s ft 4S ft. • d1Y4
5a.Well Location: /Lisks` ("K ft. 66 ft. L,a4, net
- h �jYkcx.r\ ) 5o ft 1 ft. i�,lJ�� �Y��'.L_ �--� ' ' 1
L ul wii ly, �.,, =2 ,. 1. , 1
Facility/Ow - .me Facility D (ifapplicable) ft. ft. I w" '
Y AYLS A. CAt Vr AC-gtot3 ft. ft. - FEB 1 2023
P steal Address,City,and Zip ft. ft. - Jr,:;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) 22.Ce ' cation:
3S. -9 o . 66°t2- W 1
ky,__ __
6.Is(are)the well(s) Permanent or OTemporary Signature ifie Well Contractor Oat
By sig n t rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or El No with 1 NC 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ob (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@22000'and 2@100') construction to the following:
10.Static water level below top of casing: 'L✓ (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 Infection 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) d-4D Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: t 67, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016