GW1-2023-01723_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
1\'e11 C a or Name FROM TO DESCRIPTION
%�jj •-y^� ft. ft
A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi,cased wells OR LINER if a licable
Morgan Well& Pump, INC FROM TO DIAMETER TffiCICNESS MATERIAL
ft. ft. 61/8 in. sdr21 pvc
Company Name '� p OX 16.INNER CASING OR.TIIBING(geothermal closed-loo
2.Well Construction Permit#:S�/`� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
7 IiTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge n Groundwater Remediation
19.SAND/GRAVEL PACK d applicable)
LJ Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRE LING'LOG attach"additional sheets if necess )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack ty c,grain size,etc.)
ft. Zb ft. 1`
4.Date Well(s)Completed: Well ID# ft O ft. * 1 Ax
5a.Well Location: , Oft ft.
A ft
Facility/Owner N e Facility ID#(if applicable) ft
ft. ft
�sical Address,City,and Zip
_ 21:RF.MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(ifwell field,oneellat/long is sufficient) 22.Cer anon
6.Is(are)the well(s)o,X Permanent or EITemporary Signature C fie ell Contractor Da
By sign th' rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or QNo with IS 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.
drilled:' Q 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 i(different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: y (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) D 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: 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