GW1--03902_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:/ 1 A
Javi
FROM TO DESCRIPTION
Well Contractor Name
—� ft ft.
y S � ft. ft.
NC Well Contractor Certification Number
150IITER.CASING for iiiiil4 cased ells OR=TTNTR.rL'a `Ircable==2 z
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATMUAL
ft- n
ft 6116 in.
sd21 pvc
Company Name ( r/� S6=INNER•`.GASINGORTIIBING;'e'oihermshctisedloo =
2.Well Construction Permit#: V JaL J—��_ 2o Z-1_ �J 174 1�`l EOM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply
PPY Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL;`.
Agricultural IJ Municipal/Public ft ft in.
:)Geothermal Geothermal(Heating/Cooling Supply) 4J(Residential Water Supply(single) ft ft. in.
Industrial/Commercial ©-I(Residential Water Supply(shared) 1 GROU1 .: - -
8 . k
i Irrigation FROM TO MA'r MAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring E)Recovery ft. ft
Injection Well: ft ft
__'Aquifer Recharge Groundwater Remediation
• _ i 19:SAND/GRAVELYACK rf:a"'7ica`tile _ - - -
AquiferStorageandRecovery ®IJ Salinity Barrier FROM To MATERIAL EMPLACEMENrMEMOD
Aquifer Test Q Stormwater Drainage ft ft
]Experimental Technology OSubsidence Control ft. I ft
-�Geothermal(Closed Loop) Tracer 20:=DRILLTNG3 O:G attar>iaddttionaI{sheetsitinecess _ -
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a size,etc
-- ft. ft, m d;1-
4.Date Well(s)Completed:90 Z J Well ID# ft ft 01 A Cn
5a.Well Location: (2 ft. LAI
ft ft
Facility/Owner Name n Facility M#(if applicable) ft f, J I V 2023
ft. ft-
ft
Physical Address, ft.-s,,City,and Zip 15�
'21=t RF-.MAR
0A :
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,on I tl�o Vgjdent) ¢] � 22.Certification:
�St7 [g lgl`J N n1 W
6.Is(are)the well(s)�Llx(Permanent or OTemporary SignaturefdMertified ontractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: FlYes or ONO with 15A NCAC 02C.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 record has been provided to the well owner.
repair under 421 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: I�S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulople wells list all depths ifdifferent(example-3 a(�00'and 2@100) construction to the following:
10.Static water level below top of casing: 40 (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:
(Le.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
2n
13a.Yield(gpm) Method of test: air 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:Aocompletion 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