GW1-2023-01424_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan
Well Contractor Name FROM TO DESCRIPTION
32d ft. 3Z I ft.
3572-A
ft.
NC Well Contractor Certification Number ,;15S.QIITER`CASIIVG'(for multi ased weN"AR
Morgan Well & Pump, INC FROM TO DIAMETER' THICKNESS MATERIAL
ft. y({ ft. I i in.
Company Name ,��-�j//�J 1 ;16:71YNER`CASING OR:TUBTNG" eoih rmKcclosed-:on s'` :. r
2.Well Construction Permit#: 2tJL�o ` Q6 FROM TO DIAMETER TMCKNESS �'~MATERUL~
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) in.
3.Well Use(check well use): ft. ft. ' in.
?;17i•SCREENa;`. -ter.=;cjt-•':,,'-:Z.: :-dam:!a::;`':,. ., ;�5: ;��;��i.1�;� :is':_;= _
SLOT
Water Supply Well:
FROM TO•y DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural icipal/Public ft. ft. in.
— hrigation
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial []]Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
I_'Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer RechargeGroundwater Remediation
.9i;SA1VD/GRAVE]P 4CIC(1rdli_licalile
NAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20CDZ2ILZINGT OG(attach ad"ditionaLshcetsif neces's` Js.c_i_ <'>== `=:-F. :=s
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM To DESCRIPTTON(color,hardness,soil/rock type gain size etc
— I d ft. ft.
4.Date Well(s)Completed: `�✓?�23 Well ID# 6 ft. Ka) ft. GVGe l�CYOWt* Ci
5a.Well Location: ft. ft. .,
"1P
ft. ft. i L•,6:,.�.e n~m.a -Ea'�a..,�a``
alne% trt-�ix�
Facility/Owne Name Facility ID#(ifapplicable) ft. ft. C—
I ! 6 I11V I l� ockwe LI 6 ' ft. ft.
f/V irvrr ,+,00. .-:
Physical Address, ft. ft.
ddress,City,and Zip J^
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W A S:!�_
6.Is(are)the well(s)OPermanent or DTemporary Si- ature ofC9dified Well Contactor 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: -[]Yes]Yes or XI No with 15A 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: 1166 UL) 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@100') construction to the following:
I'
10.Static water level below o to f casing:g: 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 /$ (in.) 24b.For Infection 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 •,
(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: All 24c.For Water Supply&Injection,Wells: In addition to sending the form to
0/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: !6 completion of well construction to the county health department of the county
where constructed.
i
Form GW-1. North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016