GW1--03824_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan 74.waxExzorrEs;, ,. ,y f
Well Contractor Name FROM TO DESCRIPTION- V
ft. I D I ft. I
3572-A
100 ft ft.
NC Well Contractor Certification Number
�15T:OU.");ER.ChSI�'G(formulh{:ased`.wells)"ORLI14ER;ifa•'Lcable,., , =: =
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL,
d ft. ft. in.
Company Name -.
39Z9� � ::16>INIVERCASILVG.ORTtIBING'"eotheemal'clo"sed1'oo
2.Well Construction Permit#: FROM TO DIAMETER TCKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) ft. ft. i IR
n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :17i,SCREEN,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural rilMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
_IndustriaUCommercial _Residential Water Supply(shared)
G1tOI1T
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
J Monitoring Recovery ft. ft.
Injection Well:
ft ft.
_!Aquifer Recharge E I Groundwater Remediation _
SA1�TD/GRAVEL:PACK iEa`'lic'able
ILJIAquifer Storage and Recovery E3Salinity Banter FROM TO MATERLAL EMPLACEMENT METHOD
J Aquifer Test Stormwater Drainage
!Experimental Technology [ISubsidence Control
LIGeothermal(Closed Loop) I_i Tracer .20l:DRILL-I1VG"LOGtattacti3additionahsheetsifnecess
FROM TO DESCRIPTION(color,hardness,soillrock type,-rain size,etc.)
_I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) /�
O ft. ft �/bp,.A Cta
4.Date Well(s)Completed: —� .A a . Well ID# 6 ft. 2 ft.
CAR saa"M_
Sa.Well Location:
Q
�/I OL J � ft. c3� ft
Facility/OOwr�n\erName�j{ /1(, Facility ID#(if applicable) ft. ft. „�
S3 W /" 4. V�urC . s'aLs t, f'& ft.
Physical Address,City,and Zip r ft. ft. JuiN
' i21:T2F'M`ARIZS-.'- s
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.Certification:
3s. $4 N $d.(4 1 SS W � 5-1 Z3
6.Is(are)the wells) X!Permanent or OTemporary Signature of Ce fied Well Contractor Date
By signing this form,I hereby certif'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: _)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:' a C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !10J (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 cr 100) construction to the following:
10.Static water level below top of casing: ZS (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) Iv Method of test: A r 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
chlorine / aZ completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016