GW1-2023-01540_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
�dd�'' FROM TO DESCRIPTION
m Well Contra for ae
3(k2.2 -A 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 l ft. ZQ ft. 6 1/8 1°' sdr21 pvc
16-0MER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:f•\ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permi t.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ()Municipal/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial
Irrigation
Non-Water Supply Well: ft. ft. in.
Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. 20 ft. bentonite poured
Monitoring
Injection Well:
Recovery ft. ft.
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
aquifer Test QStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) oTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO ESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)`-�DOther(explain under#21 Remarks) 10 ft (�7 ft. 1� /�,Y
4.Date Well(s)Completed: ` IV-6 \ J'3 Well IN ft. �`v ft. N�/
5a.Well Locatio ft. ft. ,.-.
j-'
ft. ft. • 4 _ . gin:' 11_. �..
FQacilay/Owner ame Facili lD#(if applicable) O ft. ft. i t B 1 2023
O Yl h^ � 1Q�l N C.22 ft ft. ; i r,:i
e-Rbisical Address,City,aid Zip ft. ft.
Kl6kh30 21. 1 �/ (�County Parcel Identification No.(PIN) N` ,`t t1\ `-'e-Kr l gO 4 ) s'�'� `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,/one/lat/long is sufficient) ` �"J 22 ''cation: i
3S. Oc�.o N „S\S 1 W 1 jl 01�
6.Is(are)the well(s)OPermanent or Temporary
Signa. .f ed Well Contractor D�e i
By • g this orm,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 A 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 1121 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.
dried:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 420 (ft.) 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 1@100') construction to the following:
10.Static water level below top of casing: 2.0 (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 ControlProgram,
FOR WATER SUPPLY WELLS
WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � V Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
IS
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount:_ 1 D 0Z completion of well construction to 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