GW1-2023-01528_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W 11 Contractor Information:
14.WATER ZONES
Well Contract m FROM TO . DESCRIPTION
ft. ft.
`,%\. ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. Iti4 ft' 61/8 in. sd21 pvc
3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM 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 Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) ',Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
Monitoring 0Recovery ft ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft ft.
Experimental Technology Ell Subsidence Control ft. ft.
Geothermal(Closed Loop) DJ Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size etc.)
A `� 0 ft. 1 o ft. fc"A A
4.Date Well(s)Completed: ! WI�a a Well ID# I ft .�rj ft. `.` __p„ 1,e*
5a.Well Location: SS ft. / �» ft. DIW,� rock
rt,h t �Y�/` (5 ft iIG6 ft. Lis�, trQh` v
Facility/Owner Name Facility ID#(if applicable) ft. V ft. 1J� '
158D5 d1d' -Nct rdY.d &EL l‘rli NL a$ae I ft. ft.
Ph ical Address,City,and Zip ft. ft
t l� 3g4 C rlt? 21.REMARKS ' td 1 2023
•
County Parcel Identification No.(PIN) in;,.,,-, , . l�
V.; -. i,.i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or �ITemporary Signa ed Well Contractor Date
%' By s:in_bert'
.form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or .M No with 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dried:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 100 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2Q100') construction to the following:
10.Static water level below top of casing: 35 (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 Injection 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) 50 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: chlorine Amount: 6 b7, completion 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