GW1-2023-02090_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan :�Ia� TD1Yrz0NE :�''z:'::_: :� ::�_°:�;;:;:::;;;:;•::::�>:;�:_:::;;;-;::�;�;:=; �:_::°:;;::-: ::<::;:°�=_:'
Well Contractor Name FROM TO DESCRIPTION
3572-A f 2's ft. V ft.
NC Well Contractor Certification Number (1� ft. 76 CL
t•:]5'O.YFTER'G:451PiG(fo"r:'mniti�as'e'd;w'ells)©T27:TNE12'(ifa"li'c'2bleiss: ;::5;:+::?:'t::F;;'':
Morgan Well & Pump, INC FROM TO DL4METER THICKNESS I MATERLAL
ft �$ ft in.
Company Name
:'Ib:INNERGr[SIIYG;ORTUBING 'eutiieebih l6seiL=1"au' :; :;5:1°:t•::;::-.:<i':::<::';t':;::;r
2.Well Construction Permit#:G"" ZLUi QZ7 FROM TO DLIMETER THICKNESS I MATERIAL
List all applicable well construcfton permirs(re.VIC,Counh-,State, Variance,eta) ft ft. in.
3.Well Use(check well use): ft. ft. in.
::1 7:SCREEN ':;ii: c:1:S::::;?.'t'r i::::::is't:::::'•:';c:;;:;::';;::;:di?6t:;:::E:::':`::tiEiE; l:`:':;::::::<::;:::;c::::tE:
Water Supply Well:
FROM TO DLAI1•IETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DM icipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriallCommercial Residential Water Supply(shared)
_ --Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft._ ft.
Aquifer Recharge Groundwater Remediation
- ::I9:+S•ri1+ID'/G12AStFE�.FACK'r£a 'licalile':•;;::'�;:;:; ::z`;,.;?r;�`: ';:::l:r:t:::;::::�:::::•:::�.':it';:•::�'�: `:�
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METAOD
Aquifer Test UStonnwater Drainage
Experimental Technology DSnbsidence Control - ft. ft.
Geothermal(Closed Loop) OTracer :20rDRI[TTNGYOG'(attach:additionaUsfieefs.iEnecess "};:!.i?:;;:.:::r;: :;;:::.: :r::_
FROM TO DESCRIPTION(color,hardness,saWroek e, ain siz eta)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. Q ft.
4.Date Well(s)Completed: Z�(��3 Well ID# ft. ft. rotv►tK�
Sa.Well Location: ft. l�J ft.
rev elo��w�LCG ft. ft
T Prey i
Facility/Owner Name Facility ID#(ifapplicable) ft' r
3756 C. V
R,614961 to 1 NG 21324 ft. ft h 1!t n O J
f[. ft.
Physical Address,City,and Zip
M
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C icati
3631 31 N 'Iq. k�07 W
6.Is(are)the well(s)a Permanent or OTemporary Sign 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: E3Yes or EJNo with 1SANCAC 02C.0100 or 15ATICAC 02C.0200 Well Cnnslruction Standards mid 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 io the well owner.
repair under#21 remarks section or on the back of lhls 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: p� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /$ (in•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy of this farm within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direetpush,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) is Method of test: Atr 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: 'Foe 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 2-22-20 L 6