GW1-2023-01725_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
0ak/ 60�CJ V 14.WATER ZONES :
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC%'ell Contractor Certification Number '1&OUTER CASING for muld-oased wells OR LINER a licable
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft' 6 ZZ ft' 61/8 in. sdr21 pvc
16.INNER CASING OR TUBING(geothermal closed-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
Agricultural E)Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring DRecovery JIL ft.
Injection Well:
ft. ft.
Aquifer Recharge CI Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 40 ft. ft. J
v i
4.Date Well(s)Completed: 17RWell ID# G ft.
5a.Well Location: O ft, Q/�ft.
l�� �C)/s ft. lJ✓ft.
/ 144e,
Facility/Owner Name Facility ID#(if applicable)
7-did oh�
Physical Address,City,and Zip ft. ft.
21.REMARKS C�
Cotmty Parcel Identification No.(PIN) — f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/�long is sufficient) 22.Certific 'on:
6.Is(are)the well(s)o Permanent or ElTemporary Si re of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well' [3Yes or EJNo with 15A NCAC 02C.0100 or 1 SA 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 Qc) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examplr-1 200'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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield m air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
(gp )oa Method of test: g
/
the address(es) above, also submit one copy of this form within 30 days of
chlorine
13b.Disinfection type: Amount: L <7 7J 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