GW1-2023-01716_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W 11 Contractor Information:
14.WATER ZONES
Well Contract —m FROM TO DESCRIPTION
ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER,CASING for multi-cased wells OR LINER d a livable
Morgan Well & Pump, I N C FROMTO DIAMETER THICKNESS MATERIAL
Company Name ft. ft. 61/8 in- sd21 pvc
3 M 16.DINER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: ' ` FROM TO DIAMETER THICKNESS MATERIAL
11
List all applicable well consnvction permits(i.e.VIC,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 MATFRie t.
Agricultural ®Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. in.
Industrial/Commercial Residential Water Supply(shared)
1&GROUT
_ _irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonfte poured
Monitoring Recovery ft ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Cif a livable
aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft fL
Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) [3 Tracer 20.DRILLING LOG attach additional sheets if necess
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
C ft 16 ft. AxrA
4.Date Well(s)Completed: Well ID# , ft S ft'
5a.Well Location: ft. ft. r
LlLK 11 ���� c7 ft r ft. J
Facility/Owner Name Facility ID#(if appplicable) f • ft. 1O
158od d1d� Ncu rdY.d kL
Ph ica�I A�dddrres�s/,City,and Zip •(�/ ft. ft
•"'VY�/�ll ) '3 l 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one llaat/long is sufficient) Q,� 22.Certification:35.5t L lj N L]U.JAS� W �1'�7 '
6.Is(are)the well(s)oPermanent or DTemporary Sign41-NCAC
o ert' ed Well Contractor Date
By s t form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or XX No with 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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (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) 50 Method of test: air pressure 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: �Z, 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