GW1-2023-02154_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only;
•
1.Well Contractor Xnformation: 1
�c(Q 1� CJ4L)Se •l4:.WA.TERZONES• . , •. .. .... .,•.. . tit
r;
Well Contractor Name PROM TO. DESCRIPTION
ft. ft.
NC Well Contractor Certification Number .
y '15;OD,rtR-G4SING,(for multi'4asea Wells)O 2Ts']rint(if D'licable)'j t.: : •,'.;
Morgan Well&Pump, Inc. . mom T DIAMETER TBIC.10M S naATERur.
+1 ft, 9 5it, 6 118/ ' 1n. sdi2t pm '
Company Name
SeL� 116 INNER CASING OR•TIIBTNG:(e6tfiefmaZclo'se3Ioop);;;,''''..r. • `;I, .2.Well Construction Permit#: FROM TO DY4a4PTKR THICKNESS MATERIAL
List all applicable well construction pennits•r.e.tile,County,Stale,Variance,a/c)- b ft. 'DO R' `') in. .Sc. 1'o ev t
• 3.Well'Use(clhecicwell use): ft. ft. in, l
• hater Supply Well: 17.SCR);EN', .. =�, _.. :'`
FROM TO DIAMETER _ SLOT SIZE, .THICKNESS MATERIAL
Agricultural aMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 14;'•esidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) fit. & in.;:18:GROUT:':.., . •.: ,�;�..
�.; ...:,,.,:: .
._. •.:•.: . .•.. .._,:...•:.......•: •.
.
ltJrrigation FROM TO MATERIAL -: EtwLACEMENTMETHOb'&AMOUNT .
Non-Water Supply Well: 0 ft. NI h5 ft. benionito- ',wail. Q„Jai P
`'Monitoring DRecovexy - ft, ft. _
Injection Well:
ft. ft.
*Aquifer Recharge 0 Groundwater Remediation
1.19:S.4,£ID/GRAVEL'.l'ACK(if appllca6ie) ';= ".•- '1 •.
*Aquifer Storage and Recovery Oi Salinity Barrier FROM TO • MATERIAL • EMPLACSh1LNT METHOD'
**Aquifer Test J]Stormwater Drainage • ft.• ft. , • '
iy4 Experimental Technology OSubsidence Control ft. ft.
*Geothermal(Closed Loop) !Tracer :2o.DRILLING.LOG'(attiiai additional ifieets ifi e`ce s.fa i ; :•:=i '.'.E.-•'•:'.
Geothermal(Heating/Cooling Return) Other(explain under#21 arks) FROM TO DESCRI TiON(cola,hardness,sotllreck typo grain size etc.) '
f p ft. ft. p;r3'
4.Date Well(s)Completed[���'t' Well10# f fa. ft. /" ft. E,,,i 40,11" .
5• Ta frig d- _ / SD ft. D ft• lb f.>� �bc�`'
// i. T
O fG p fit ' ' =ri 5,
y _ 1 ink- �jf�,%�
Facility/OwnerName Facility IWl(if applicable) 1 b ft. /L o0 f- 1)'(/
W ft. g MAR ,) :, 2n?3 .
r.t i - ft. ft.
• '
Physical Address,City,and Zip ft. ft . ... _ . . ' .
County Parcel IdentificationNo.(PITS) 0 i t/ If,t Ourr g i-I % f ii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fl tIL -
(ifweU field,one lat/lone is s dent) 22•Certification:
3 c is -N d. g5Ts/ ..
6.Is(are)the weII(s) Permanent or Temporary
Signature of Certified Well Contractor :•Date/— 7�'v
By signing this form,I hereby certify Mat the wells)was(were)constructed in accordance
- 7.Is this a repair to an existing well: J Yes or' I No with ISA NCAC 02C.0100 or 1SA NCAC 02C:0200 Well Consultation Standards and that a
gilds is a repair;fill out known well construction informaiian and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 4121 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 TOTALNUMBER'of wells construction details, You may also attach additional pages ifnecessary.
drilled: - SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: CC-) (ft) 24a. For All Wells: Submit this form within 30 dayk of completion of well
For multiple wells list all depths tf different(example-3( 200'and 2@.100) construction to the following.
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
IfIvater level is above casing„use"4•"
1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter; 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a •
�—f`}Y d above,also submit one copy of this form within 30 days of completion of well
12.Well construction method; r U 1 "r construction to the following. -
(i.e.auger,rotary,cable,direct push,etc.) . •
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, •
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm} �V - Mefhod of test air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
�1 ' the address(es)'above, also submit one copy of this form within 30 days of
13b.Disinfection type: (4�c>)0f Amount: �fl�/ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2 22 2016