GW1-2023-02487_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
!� L-4 WATERZONES;::,.`i
FROM TO DESCRUTION
We o c rName ft• ft.
� 4 —i, ft ft
NC Well Contractor Certification Number v;15iTOUTER`.GASING`foe multi`eased'+'wel]s:ORTiINER`:rf`ii li--ble
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL'
1 ft ft 61/8 m' sdfL1 pvc
Company Name w��� `i'6 INNElZ CA51NG URTUBII�LG; eotfie mat cloCYCgE5 =Tt°F
2.Well Construction Permit#: FROM To �11WIIE�TERTHICEIVESS MAr ERiAr.List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) f
ft ft in.
3.Well Use(checkwell use):
1ZSCREEN -
Water Supply Well: FROM TO' 'sy DIAMETER SLOT SM THICKNESS MATERIAL
Agricultural [Municipal/Public ft
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft, in.
{_:Industrial/Commercial __I Residential Water Supply 1 (shared)
) .:18:GRODT `�'`;'<c"✓`i.'':"".'�:'_.'.._.,.. ......:.-.:::;:.,,.,:..,:�... ._._ _ . ...:..-,-
ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
_i Monitoring DRecovery ft ft
Injection Well: ft ft.
I_ Aquifer Recharge n Groundwater Remediation
�- .19cSAND7GRAVELRACICCXi"-"licable--a;:?: <`:-"it'';
_I Aquifer Storage and Recovery MSalinityBarrier FROM To MATERIAL - FA2LACEMENTMETHOD
L Aquifer Test []Stormwater Drainage ft ft
J Experimental Technology [3Subsidence Control it ft.
Geothermal(Closed Loop) �ITracer
20:DRIL7; TGTO.Gattac7iadditionsIs`hee[sifrieceas': r3'.;;� ._:_*::•. :..-.,
FROM TO DESCRIPTION Color hardness,saillrock e, size,eta)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) b ft b ft r0
4.Date Well(s)Completed: �� Well ID# d ft ft Vo
l /0 ft. zoo ft
'
Sa.Well Location:
� ie �Y
► i ft ft.
Facility/Owner Name Facility lD#(if applicable) ft ft v� y
rk Rem �.Jr IiR.f��"bJ ft ft (� l
c it ft APR 0 6' l� J
Physical,Address,City,and Zip
11�1T116� `.�2
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q 22.Certification•
• e C red Well Contractor Date
6.Is(are)the well(s)jIPermanent or Temporary Signatur
By signi this rm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or INNo with 15A NCAC 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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. 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: 2.00 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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 (in.) 24b.For Iniection Wells: In addition to sending-the form to the address in 24a
rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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) Method of test: air pressure 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
granulated chlorine completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P
where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j