GW1-2023-01542_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
zoq Todd v�¢ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
qssc0-4 ft. ft.
NC Vi ell Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. O1 ft. 61/8 In. sdr2l pvc
Company Name I �J
���6 j 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 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 QMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,�
hardn soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) h GD fL y-1 ra /1 di
>
4.Date Well(s)Completed: I` 17-23 Well ID# 90 ft' 17704 ii. /3/p l 400/4
5a.Well Location: ib aft. 2�foft 3/146 00'P*4-6
1�'�r( I ie 5 c0� 0`I• ft (� ft 1 I
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1/ " i elel n 0 ci,I t S ft ft. a...,.
Physical Address,City,and Zip ft. ft.
w� 21.REMARKS r N I 7.-) Z023
ps,County Parcel Identification No.(PIN) • : >-.,:;;r Ur..i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
SC-0 f q76 N 99. V w l _l7 -13
6.Is(are)the well(s)Dx Permanent or DTemporary Signatur eft' a 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: ®Yes or _U 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-I 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: _(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 2@100') construction to the following:
10.Static water level below top of casing: J 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 Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(gpm) I Z, Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: q o t, completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016