GW1-2023-01543_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
U Q �Q �� FROM TO DESCRIPTION
r ^ /j ;_; .-e 4: 4...L.,> ft. ft.
, -
FEB ft. ft.
NC Well Contractor Certification Number F_.D 1 •- 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC ,r�Lll,, FROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft 7 Z ft in'
6 1/8 sdr21 pvc
e e> �] 3'✓t 16.INNER CASING OR TUBING(geothermal dosed-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
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural 0Municipal/Public ft ft. in.
IDGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
0Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft* bentonite poured
Monitoring Q)Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 10 Subsidence Control ft. ft.
f Geothermal(Closed Loop) OTracer '20..DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothennal(Heating/Cooling Return) 0Other(explain under#21 Remarks) ft. ft ^ 7
s � 4w1Ai
4.Date Well(s)Completed: I Well ID# I n ft. �O ft 5otr d I 1 t d i
5a.Well Location: Go
ft. ` ft. �� n
eW Pa / (off ft- f' 1 (?An t-t )
Pr
ity/Owner Name Facility 1D#(if applicable) ft. ft
l.6 col ! eA t r y K,d' ft. ft
Physical Address,City,and Zip ft. ft. —
0- 21.REMARKS
0 VAVI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - 1
(if well field,one lat/long is sufficient) 22.Certification: 7
, /. 32 N Po. 7�g9 W 7 40,9
J`lo 3
6.Is(are)the well(s) X Permanent or Temporary Si,. of Ce ',7Contractor Date
By signing this form,1 hereby certin)that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or E 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.
wed:' ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 66 (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 c)100') construction to the following:
10.Static water level below top of casing: 10 (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) l c 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: 4 .5 OZ 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