GW1-2023-01715_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris Morgan 14 weaEirzo k ;K71
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
3572-A /49 ft. ft
NC Well Contractor Certification Number `,AKOUTER CASING(for:multi-case&wells)OREMER tf i
livable
Morgan Well& Pump, INC FROM To DIAMETER TI3ICKNF-' M+TERw
ft ft in.
Company Name
. n,,A I&INNER CASING OR-TUBING eothermal eloied400
3 2.Well Construction Permit#: N3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.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
Agricultural E cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial E)Residential Water Supply(shared) 18'GROUT
hTi atlon FROM TO MATERL4L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
_ Monitoring ORecovery ft ft.
Injection Well: ft. ft
_ Aquifer Recharge [)Groundwater Remediation
<Y9;SAND/GRAVEL PACK"Cif$"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology []Subsidence Control ft. ft.
RGeothennal
Geothermal(Closed Loop) (Tracer 20 DRH,TINGLOG atti¢lia&ditibnalsheetsifnecess(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Drain size,etc.)
O ft SU ft.
4.Date Well(s)Completed: L 2 Well ID# fr. / ft.
Sa Well Location: ft ft. G e
Facility/Owner Nam (, Facility
IID_#(if applicable) ft. ft.Y�� �._�, Wes.1�.— ft ft. �-t� 1 .: Zl'n
23
Physical Address,City,and Zi ft ft.
� 766 �3 a
7.1 REMARK
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.C fieation:
N W /z�-0
6.Is(are)the well(s)OPermaneut or OTemporary Signature of C i d Contractor Date
By signing this rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: �Yes or X®No with 15A NCA 01C.0100 or 15A NCAC 02C.0100 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.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 266 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example--3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: 46 (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) Method of test: Ar 24c.For Water Supply&Iniection 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: SOS completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016