GW1-2023-01727_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
`{�J(� s 14.WATER ZONES
�� — FROM TO DESCRIPTION
Well Contractor Name
ft, ft.
/r-4 L'?� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-med wells ORLINER a livable
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name tt. 110 ft. 6 1/8 in' sd21 pvc
2 16.INNER CASING OR TUBING eothermal closed3oo
2.Well Construction Permit#: 1-11(p� (J FROM TO I DIAMETER THICIQ1ESs MATERIAL
List all applicable well construction pe mits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROMCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) rnResidential Water Supply(single) ft. ft. in.
Industrial/Commercial NResidential Water Supply(shared) IS.:GROUT
_1 Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. bentonite poured
Monitoring DRecovery
Injection Well:
ft. ft.
:_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable
Aquifer Storage and Recovery 0Salinity 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 type, rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM
ft.
4.Date Well(s)Completed: I-zq Z�>Well ID#
5a.Well Location: , t ft. /1-711�
ft
i
Facility/Owner Name Facility ID#(if applicable) ft. ft
Physical Address,City,and Zip ft. ft.
21.REMARKS
C unty Parcel Identification No.(PIN) — 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: h
(ifwell field,one lat/long is sufficient) 22.Certification: :,',';`
6.Is(are)the well(s)ID Permanent or [3Temporary Signature ofCet Tied Well Contractor Date
By signing this form,1 hereby certify that the weills)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or X®No with 15A 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:' CC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I LJ (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 3D 00 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 Infection 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
air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 8
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: chloflne Amount: r� completion of well construction to the county health department of the county
where constructed.
I. :i G%' North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016