GW1-2023-02501_Well Construction - GW1_20230406

^Print Form`--
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
FROM TO DESCRIPTION
We o c Name
it. ft.
ft ft
NC Well Contractor Certification Number ^ '
1 S::OiJTEWCARNG:fah malt*iis- dwells'012I INER iE:a hi ble ;:;:
Morgan Well &Pump, INC Fxoni T DIAMETER TffiCKNESS MATERIAL
1 ft ft- 1 6118 m' sd21 pvc
Company Name J �
Q(� =:-I6.-INNERCPiSINGRT�OOBING- eathdhffiw
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS ~MATERLAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
PP y FROM TO �7--
:D) SLOT SIZE TffiCENESS MATERIAL
Agricultural []Municipal/Public ft ft
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft.
i_hidustrial/Commercial I_ Residential Water Supply(shared)
EIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: 0 ft 20 ft' bentonite poured
Monitoring DRecovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge D Groundwater Remediation
19.`SAND/GRAVETiPACK d=a licatile"r`.:i
=i Aquifer Storage and Recovery IJ Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OI Stormwater Drainage ft ft.
Experimental Technology LJ Subsidence Control ft. ft
R
Geothermal(Closed Loop) �ITracer 205DO.G:ats7%additionahyhe'efsif`n'eeeas"- '.' "Geothermal(Heating/Cooling Return) _�Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sofitrock type,grain size,etc.)
D ft. �� ft
4.Date Well(s)Completed:?)[ Well ID# V6 ft. 16 ft.
5a.Well Location: ft. ft
ft ft
Facility/OwnerNatlp, ` a #fj(ifapplicable) ft ft. ^• `" i?t,�
(f ft. ft APR 3
( ft ft
Physical Addres, r p J
'21:=REMARKS: �J
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.Cer' nation:
35. E N�®30 -6 R w f
6.Is(are)the well(s)g jNrmanent or OTemporary Signature edWeITContractor Dat
eF
By signi th' rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Wo with 15A C C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis re r has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: 2JP0 -(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@200'and 2@100) 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 (in.) 24b.For Iniection 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) A� Method of test: alb 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
13b.Disinfection type: granulated chlorine Amount: 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 2-22-2016