GW1-2023-02532_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
-14.WA.TER'ZONES`-i:; :,�S=�i+n-JY':-. -
FROM TO DESCRIPTION
We// on c rName ft. ft.
�E lS�•• ft ft.
NC Well Contractor Certification Number
::1SUVPER'.EA$ IIs.OR=ISNER if.a bcable
Morgan Well &Pump, INC FROM To DIAMETER THICKNESS MArFRrer.•
1 ft ft 6 1/8 m' sdr2l pvc
Company Name 16 •Jw r ::r".:.�..
.rIlVDIERCAS I G.OR•7'IIB ING"2.Well ConstructionPermit#: N Ilk FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.)
ft ft. in.
it ft in.
3.Well Use(check well use): _ _
;"_;:"'7.z::�`"`:
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
:)Agricultural MMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, in.
J ❑
_Industrial/Commercial [31(esidential Water Supply(shared) 18 GRODT` ::`:.";
hxi ati0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft, bentonite poured
r!Monitoring DRecovery ft ft.
Injection Well: ft ft.
f Aquifer Recharge [)Groundwater Remediation ,;::;.;;-
.19"SAND/GRAVEL P.1 if a linable: :i
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage ft ft
J Experimental Technology OSubsidence Control ft ft
"20.DRILL�VGTOG a[tali:additionsI'sHeetsif:riecessa - " ':: '> 'r;:':
Geothermal(Closed Loop) UTracer
FROM TO DESCRIPTION color,hardness,sm7/rock type,grain size,
_i Geothermal(Heating/Cooag Return) J Other(explain under#21 Remarks) D ft 5 ft
4.Date Well(s)Completed ` Well ID# t 5 ft. �� ft.
3® ft.
5a.Well Location:
VI> ft
ihf h �L�O l�O.['•�_1n ft
Facility/'Owner Name n , r Facility ID#�(if applicable) ft ft
1S l L0 sw C� �9�C�1� NL l� ` 1 ft. ft.
Physical Address,City,and Zip ft ft APR l_
'21REMAR10 `is
� yVcaS ..it�,:..�i~.�-• :,�,...':.•`.:;��.°.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(2ifrwelllfield,one lat/long is sufficient) �+ 22.Cer' atioIlj
7�►y�j�� N a �35 W C�� �►�
6.Is(are)the well(s)SPermanent or Temporary Signa o ertified Well Contractor Date
By i in form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or J@No wi 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction'Standards and that a
If this is a repair,fill out(mown 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 ofthis 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: 00 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (N 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 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) Method of test: air pressure 24c.For Water Suuuly&Iniection 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: �d p'Z completion of well construction to the county health department of the county
where constructed.
North Carolina Department ofEnvironmental Quality Division of Water Resources Revised 2-22-2016
Form GW-1 P Q n'- I -