GW1-2022-10156_Well Construction - GW1_20221110

r
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: P
1.Well Contractor Information: I
i
Chris Morgan
FROM TO Y DESCRIPTION
Well Contractor Name ft. 4
3572-A
ft. ft.
NC Well Contractor Certification Number Y5:'OUTER'CASING'fo 'mulh4ase$'w`e71s`;OR`L wmE rf-s `lieu
Morgan Well & Pump, INC FROM TO DIAMETER TffiCIQVESS MATERIAL
ft. 2 ft. in.
3.
q p 16 INNER;CA$WG`sOR:TUB
Company Name r J ING.'''eothermaliclose8 l00`"`
2.Well Construction Permit#:��1 6 FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well consnruction permits(i.e.VIC,County,State, Variance,etc.) ft. ft. rn•
3.Well Use(check well use): ft it to
,­17,SCREEN
Water Supply
Well: FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
Agricultural [IM cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18::GROIIT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring DI Recovery ft. ft.
Injection Well: ft. ft.
i Aquifer Recharge ®1 Groundwater Remediation
19'SAND/GRAVELtPACK`ifd 1'icatile rs .�r r. ._.. •. _
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer A DRILLINGL,'OG:(atticbCidditiodalilig&iif:i ecess _ -
FROM TO DESCRIPTION(color,hardness,soil/rocktype,~ rain size,etc)
NJ Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks) ft. 16 O it. R
4.Date Well(s)Completed:10-Z7-ZZ Well ID# 41
ft. 0a ft. ro K
Sa.Well Location: ft. 110
25
�(1dh JOWIC.e. 1 ft. Sit/ ft. draw
/!
Facility/Owner Name Facility ID#(if applicable) N
2 -r1f0.1 ' S•`�^ 1ML ft. ft.
Physical Address,City,and Zip
G�f/7� .;21 i2FMA'RKC t - a
Clcyx�anld. 17 7 L-1 -
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.Certi icatio : I,oww 4on PfacMM49 UrA
35.4 0 5g N Wa A, 0111c iX3
6.Is(are)the well(s)OJx Permanent or Temporary Signature of Ce red well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n Yes or XI No with 1 SA 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: tic) (ft.) Division of Water Resources,Information Processing Unit,
If water 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) I. 5 Method of test: 4,`r- 24c.For Water Supply&IniectiJon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
chlorine ? � completion of well construction to the county health department of the county
type:13b.Disinfection e: Amount:
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016