GW1-2023-01428_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number
-:f5.--OUTER.CASING'(fdi.ii2iifti-6iii well R. R!(i6 li6able),-;­,''­,',"
Morgan Well & Pump, INC FROM TO q I DIAMETER wells
11 MATERL41,
I'- ft' 1 6 1/8 1, in. d,21 Pvc
Company Name
2.Well Construction Permit •Lam' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) i
ft. n.
3.Well Use(check well use): ft. ft. in.
��Water ater Sup e :t.17;SCREEN�.";;
pll: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rIMunicipal/Publir ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft.
DIndustrial/Commercial 61 Residential Water Supply(shared) '18' OUT--::-.
h-rigation FROM TO MATERLAI EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite, poured
DMonitoring EIRecovery ft. ft.
In
jection
Groundwater Remediation
pp )19.SA"IGRAVEI:,PXCK(If-a'- licibk
3Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStonnwater Drainage
Experimental Technology
DSubsidence control
Geothermal(Closed Loop) DTracer
Geothermal(Heating/Coo ling Return) 00ther(explain under#21 Remarks) FROM TO DESCRTPTION(color,hardness,soil/rock type,galn size,etc.)
4.Date Well(s)Completed:. Well ID# 4oc. It. Rnwn O.VkL
5a.Well Location: ft. b4v I
is Wak"e ) Aq 0 ft. ft.624"a Z)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Da Lf-,j FEB -8 2023
Physical Address,City,and Zip� Una
'21.�P
a z_-6A� . EA1ARKS'-"
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.Certi9cation:
3C N
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well 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: DYes or QNo with 15A JVCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in and explain the nature of the copy of this 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:I SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 7 ('0 24a. For All Wells: . Submit thinsform 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:
10.Static water level below top of casing: 40 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,lUfiderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC.27699-1636
13a.Yield(gapin) -Method of test: air pressure 24c.For Water Supply&Injectio Wells: In addition to sending the form to
chlorine the address(es) above, also submit one copy of this form within.30 days of
13b.Disinfection type: Amount: completion of well construction t<o the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016