GW1-2023-01581_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-'1) For Intemal Use Only: 1
1
1.Well Contractor Information:
Chris Morgan . I4z.--ATE2z0NES;
..........:..... ....
CRIP
Well Contractor Nam FROM e I
ft. TO DES TION1 .
3572-A 1 It ft.
ft, ft, i
NC Well Contractor Certification Number
.>15'FIFITEIt;'CiiSINGr:'(fo's`multi=cased':"weltsk'Ols;'•FiTNER`(ifa' &caESle' i <ii>:::'t::? :
Morgan Well &Pump, INC FROM TO DIAMETER THICICPtESS ivL4TERLAL
ft 6e2 ft I in.
Company Name (!
LL ::`I6dEINNE1tCASIWWG;OR-T ING 'eSttiermaF'closed=ldu' ;;ia:e:: ':<a::: :s: F•';`i:: :::i'
2.Well Construction Permit#: I` 6N. FROM TO DLANIETER TMCRNESS MATERIAL
List all applicable well conriniction permits r e.UIC,Couny-.State, Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use):
::I7:'SCRL']L1�4f;[ti•+:;'::::::; :.`E:�':� - ;:`::: '•:::r.':?:tit??i2:;:::t.'`::: tt;`::.Y:E:
Water Supply Well: FROM TO DIAIYIETER ! SLOT SIZE 7TITCISYYESS MATERUL
Agricultural rcipal/Public it it
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
:lndustriallCotnmercial [_•�,Residential Water Supply(shared) ............:.:... :.::
:....:::..:::::::. :::•:::..:::::.:::.-:•::::::. :..:::::.::•:::.::. ..:.:.. :..:..:.:•:::.::::
Tizi ation FROM TO MATERAAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft bentonite poured'
:Monitoring E]Recovery ft, ft.
Injection Well:
ft ft.
Aquifer RechargeGroundwater Remediation
`•'19::$ADMIG1241T1E1 PAt3{• .- 'livable'::±`:?: ;c:::=:;:;:<;€>::;;;; ':t ::=t:i;:i t:i•:[r,;;t::::;;''
Aquifer Storage and Recovery [38alinity Barrier FROM TO hL4TERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft1B
ft.
Geothermal(Closed Loop) Tracer ;c20 DItII DTNGI
:..:•.
Geothermal(Heating(Cooliug Return) E3 Other(explain under#21 Remarks) FROM TO DESCRiPTTON(color,hardness,soill-ek type.g2lEs"eta
ft ft
ro
4,Date Wells)Completed:, 'Z Well ID# 31 ft (b ft' V-
5a.Well Location: ft, r' ft• m n"r
Facility/Owner+Name e,/!� Facility ID/#(if applicable)
1 I ft ft.
1%6 C{�IAGs -a�� TONArj G7t W12f1 / r �"*ol� ft. ft
Physical Address,City,and Zip JJJ ft. ft
Gas
ovl .5xxJ
6t i
b
CJ�f 2I:
r t D _
9 2,L
23
REMiRKS�
:.....:.:.............:.::....:
UITA
County Parcel Identification No.(PIN) -
I.i v Y Vtt i7•.J'•w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Cerjcation:
N W
6.1s(are)the well(s)Ox_ Permanent 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- E3Yes or JRNo with 15A NCAC 02C.0100 or ISA 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 remarh 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 some You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Inidicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed: SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 165 (ft) 24a. For All Wells: Submit this I form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200 and 2@100D construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter: 6 1/S (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-
(Le.auger,rotary,cable,directpush,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: 1 r 24c. For,Water Supply&Inlectibn 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: OZ completion of well construction tot the county health department of the county
where constructed
Form OW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources i Revised 2-22-2016