GW1-2023-02515_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan !4.f,wA ZONES >h.,.,:r
FROM TO DESCRIPTION
Well Contractor Name
It. f
3572-A �b6 61 t.
ft. ft.
NC Well Contractor Certification Number
veIrwo
s15t0.UTER.CASI)\Cr(for.mu`lh casedyRI IlYER.rF'a iticahl'e 1 '""_"
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. rAq ft. 5 in. � A G
Company Name
� / /n 16.INNEIRCA$ING�OIZTLJBING."egthermal c7osedloo': v �c�_ �::� ,:;
2.Well Construction Permit#: F14 W-ZZ—41,2 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.'SCREEN;.;.:;.:e.'s. .'.�.:�u.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural _jeridei,]
a]/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft. ft, in.
_i Industrial/Commercial DResidential Water Supply(shared) 18'GROih':tr`c:
Irrigation FROM TO MATERIAL EMPLA CEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. pp ft. bentonite poured
_I Monitoring ®Recovery
Injection Well:
ft. ft.
_!Aquifer RechargeGroundwater Remediation
t b1D7GIt AVEL A
Aquifer Storage and Recovery [ISatinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
_!Experimental Technology [(Subsidence Control
DRLFVGLOG'aofiadioGeothermal(Closed Loop) ©Tracer 20 alsu;je.xifnece`s's'
') __ ,..;_.:•.-: .-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
_ii Geothermal(Heating/Cooling Return) '- i Ocher(explain under#21 Remarks) ft. s ft o W C+ l
4.Date WeIl(s)Completed: Well lm# 6 ft. 1 165 ft.
5a.Well Location:
Facility/Owner Naame Facility ID#(if`applicable)
7Q [7 O .Lv\, Lyan %J�anjd 4 ft. ft.
Physical Address,City,and Zip ft. ft.
ii21{:RFM'Al2KS•• - tfl.Y 4* t Y79.75CMI.-'}c7 -
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 f non:
el
35• -!57.6 N 96- IJ36 W
6.Is(are)the well(s)OPermanent or OTemporary Sigoatm ofCerti (Contractor Date 1
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: I.J Yes or XI No with 15.4 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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 6S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(20`0'and 2@100) construction to the following:
10.Static water level below top of casing: �J (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 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) 15 Method of test: Air 24c.For Water Supply&Iniectio I Wells: In addition to sending the form to
the address(es) above, also submit bne copy of this form within 30 days of
13b.Disinfection type: Amount:
chlorine �j OZ completion of well construction to the county health department of the county
where constructed.