GW1-2023-02533_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WeII Contractor Information:
Chris Morgan rx
FROM I TO DESCRIPTION
Well Contractor Name 16S ft. 1&6 ft.
3572-A ft �ttJJ ft.
NC Well Contractor Certification Number
'�15�QUTER:CASI9G;foJ�mit3h-casedwells):OR7�INER'(if`a hcable
Morgan Well & Pump, INC FROM TO 1 DIAMETER I TffiCKNESS MATERL4,L
ft. 7 ft. in. 2.6e I fl V`
Company Name V1�
nR, r� 16 r1NL+TIItCASING,ORsTUBING "e'othermhLi 61
2.Well Construction Permit#:?�?��(So uz FROM To DIAMETER THICKNESS MATERIAL
List all applicable well connst action permits(i.e.UIC,Count),,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water SupplyWell: FROMREFNu
TO `DIAMETER SLOT SIZE THICKNESS MATERIAL-Jl .
Agricultural" QM icipal/Public ft. ft. in.
i Geothermal(Heating/Cooling Supply) Qk6sidential Water Supply(single) ft. ft. in.
IndustriaUComme cial �Residential Water SuPP1Y(shared)
:'<:`; -; :.,�.:;.' ;- =� � :''`-.=�� __•"���::-==' -
Irrigation FROM TO` MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. bentonite poured
_,Monitoring Mi Recovery ft, ft.
Injection Well: ft. ft.
Aquifer Recharge [3 Groundwater Remediation -
�19 1SA`iI)/GRAVEL.PACIC t�"a"`licatile,.. s.. . .
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test •DStormwater Drainage
Experimental Technology L;Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 1'_'20--DRH:,- GZOG-:(at[acli a'dditional`s3eetsi£ne."c`ess"`j:=- _ w;=%'yii-•'i'1=-?-;
_ FROM TO DESCRIPTION(color,hardness,soil/rock type,main size,ete)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
O ft C/ ft G1et- C
4.Date Well(s)Completed: 2-27�23 Well ID# ft. 7 s ft n 54
ft. 6 ft r
5a.Well Location: 776 V
QnLA
ft. _
ft.
Facilityy//OQwnneerName Facility D#(if applicable)
ft. ft.
2g85 DENY lci r�• C'o�col-A. �,2�2� ft. ft APR r 2023
(
Physical Address,City,and Zip U ft ft.
�r t
,21REMA•I2KSr.�'Si�i"��� 5 +^taA-' .•.r+r r.� -
('aharrus - `-
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' cation:
Z.(P�6? N ��, S6 �3 W Ok
6.Is(are)the well(s) Xi permanent or Temporary Signature of C rti ed a Contractor Date
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: �J Yes or XI No with 15A NCAC 02C.0100 or 15.4 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: �Gd (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00D 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: I 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: A 1' 24c.For Water Supply&Iniectiol 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: 70Z completion of well construction to the county health department of the county
where constructed.