GW1-2023-02177_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD (GW 1) For Intemal Use Only:
1.Well Contractor Information:
Chris's Moran -
a"1 .Vl'ATRl2fZONLS::':'r.'`?:`.:l:�:t::�::::';`::�;;::�:;;�<�:�_=t :?;z;::;::'i;:::;;;::::;::< Ct::r:;;•:;;:;::,:';::�:aFi:::
Well ContractorNarne FROM TO DESCRIPTION
S!�' ft. ft.
3572-A O✓✓
ft ft,
NC Well Contractor Certification Number v
'b.LFTER'CASING(forrmu1R�'ss'edw'eIIs)OfiIIYER'(ifa
Morgan Well &Pump, [NC FROM To DIAMETER THICKNESS MATERLAL
ft. i I3 ft in.
Company Name `I� • .. . ..
r l �j INNE1t GAST1`IG;OR:TUBING gddt er F'closed.-18u' ::::`:,::::•:;:;._: ;,;.::;::t;!;::::`
2.WeII Construction Permit#: l�l O J1 FROM TO DTAIVIETER TMCKNESS MATERIAL
List all applicable well cautruction permirs(ie.UIC,Couny,,State, Variance.etc.) ft. it. in.
3.Well Use(check well use): ft. ft. in.
1 S CREEK:`'a' ?:''.::::::::::::�:'•is:?':::�;�:i_:(tt:: '•:::::,•:r:?::;:5:�:::��::': :::::z>;;:: :•:'r`''.:�l.i�:::;::::::
Water Supply Well: 7 .. .
FROM TO DIAMETER SLOT SIZE THICKLY-ESS MATERIAL
Agricultural bZdel.tial
icpal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Water Supply{single) ft. ft. la
Industrial/Commercial Residential Water Supply(shared)
O .
Irri ation FROM TO MATERiAt, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
:Monitoring [)Recovery ft. ft.
Injection Well:
ft_ ft
Aquifer Recharge rIGroundwater Remediation ;._.;.:.;;.:....
i�i19::SAPID/G12'eIV�:PACI{'i€a 'licable':1:�::: ;:•:::�:=;;7:�ii?il��i:i;'t;::::-t::.':::::it::;<;:;:..>s::::::::::t::
Aquifer Storage and Recovery Saliniry Barrier FROM TO MATERIAL EKPLACFNFENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer r:26::DItII1NGl'OG(sttacfi'additioriaksHeets.ifnecess .)' : : s:::;;;<::;:; :. ::i;? :
Geothermal(Beating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTTON(color,hardness,soiVroek &
`b rain size etc.)
ft. ft.
4.Date Well(s)Completed: 2��"�� Well ID# ft. 165 ft.
5a.Well Location ft. ft.
ml
ft. ft
Facility/�ame Facility ID#(if applicable) ft. ft -.
�6 V D Or(14W4 a. san�k - � 156 ft. ft.
Physical Address,City,and Zip ft. ft. MAN t.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one
lat/long is sufficient) 22.Cer' atioIl
35.196 l N ` 0
6.Is(are)the well(s)Ox_ Permanent or 1ITemporary Signanue ofCetti red Well Contractor Date ,
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EJNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erploin 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:' e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(e_cample3@200'and 1@I00`) construction to the following:
10.Static water level below top of casing: 13 (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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 36 Method of test: A"r- 24c,For Water Supply&Injection Wells: In.addition to sending the form to
chlorine
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ?Ot 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