GW1-2023-02492_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris MorganFROM •TO DESCRIPTION
Well Contractor Name ft. it
I ft.
3572-A 1
ft. ft.
NC Well Contractor Certification Number
1:1§.OUTER CASIIVG(fae.mulli;cased',�vells"OR7111!IERf if a"'lic=: -.
Morgan Well & Pump, INC FROM TO DIAMETER TEICKNESS MATERIAL
Name ft. 14V ft. /_ in-
Company
V V V
2 A wt .�-6 INNERCAS):NG OR}Ti1BTNG"'"e'o"therniaL
2.Well Construction Permit#: O 85 /d FROM TO DIAMETER THICIQVESS MATERIAL
List all applicable well const uction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): M ft. in.
Water Supply
PP Y Well: FROM TO DIAlV1ETER . SLOT SIZE THICENESS MATERIAULL
-11 Agricultural l_I Municipal/Public ft. ft. in.
71 Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. -ft. in.
du trial/Commercial Residential Water Supply(shared)
In IJ S � PP 5'(h -
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, bentonite poured
I Monitoring Recovery
Injection Well: ft, ft.
_!Aquifer Recharge il Groundwater Remediation =
f9 SA1�D'/GRAVEI PACK'if a licable ;
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
-Aquifer Test Stonnwater Drainage
!Experimental Technology '©,'(Subsidence Control
t3Geothermal(Closed Loop) I_i Tracer h`20iDRILLING:LOG(atitacfi*additional'sheets riecess` -_ -. == ::;-r
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,eta)
I Geothermal(Heating/Cooling Return) � Other(explain under#21 Remarks)
- a ft. Z6 ft. C(
4.Date Well(s)Completed: 3 I�Z.� Well ID# Z ft. Z6U ft' �r �-
ft. ft.
5a.Well Location:
ft
' J ft.
Facility/Owner Name Facility ID#(if applicable)
92- I5 Ce SQ!; Vr l— ft. ft. O
023
Physical Address,City,and Z�
`J O-50 :211RF.MA"RKC 30• ,_utc '+ :� --,.,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 4aA /��Q Q� 22.C '[cation
31S Se' lb N JOO W
oy
6.Is(are)the well(s) XJ Permanent or []Temporary Signature of Certifie a Conhactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ri]Yes or XI No 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 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: 20 CS —(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 2900'and 2Q100') construction to the following:
10.Static water level below top of casing: �� (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: 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: �`Ir 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: completion of well construction to the county health department of the county
where constructed.