GW1-2023-02182_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan ;:�14t;:WATER. NE ............. . . .. . . . .. ...... . ._ ...
Well Contractor Name FROM TO DESCRIPTION
3572-A 0165 ft. 766 fL
NC Well Contractor Certification Number :>
a:I50.LITER'CASIPT�(fo'rmulti=cos'ed<iiells}'Ok`Ti'I1VER'(if�a L'caSlez;:;:aal:?:>.`.-a::::•:::;:
Morgan Well & Pump, INC FROM TO DIAMETER T$ICEStEss MATERL4L
ft. f 73 ft in.
Company Name 1 1
1 ���� :I6t:INNERCASIPIG;OR:TUBING eotfiermaE'close3=lou' e;=S:;:i: ;rt;•': :i''::::;:':
2.Well Construction Permit#: FROM TO DL4,METER THICKNESS MATERIAL
List all applicable well construction permits rz.e.UIC,Count),,Stale, Variance,etc.) ft ft. rn.
3.Well Use(check well use): ft rn
cSCREEN S( :.....:...;:'S:
Water Supply Well: F
ROMTO AIM•IETER SLOT SIZE THICKNESS MATERL4L
Agricultural [DMunicipal/Public ft.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. in.
Industrial/Commercial �__.•�,Residential Water Supply(shared)
EJ' T';;r:t::t:':i:=::: E:;::::;i7::;::::::.'::::::::::::::'::`_ I1ii ati0n TO NLITERL4LEMPLACEhfENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft bentonite poured
Monitoring DRecovery ft. &
Injection Well: ft., ft.
Aquifer Recharge E)Groundwater Remediation
_ ;•19::$tiPIIlIG12'e\T'.EU.PACK'tf a 'licalil8 t: ::•':::: �: ::;>:;;c ::::'<i::.'t::i; �z:�:�:::;:i:::::;:a:
Aquifer Storage and Recovery Salinity Barrier FROM TO i4L4TERIAL ErY PLACEAiENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ZlkMuff1NGE0�'(attacHaddiiioaals&eets.iEneCess
FROM TO DESCRIPTTON(color,hardness,sail/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return} Other(explain under#21 Remarks)
"' 0 ft-
-f'JK
4.Date Well(s)Completed: 'z-2�23 Well ID# ft ft. &
Sa.Well Location: ft. 95 ft.
gode(5 W ft. 7% 11L
Facility/Ov ner Name Facility lD#(iif applicable) ft. ft
1031 DaylS Gru1� 6. avIk �ff ZION ft. ft
Physical Address,City,and Zip
::21�>:>+.n-ra arr�.::::::�::;::;x:::::::::::::::::=`i:::�:� ';:�s:c�::�'il°:its�;;>;;x:+;.•;:% :4:>�;.:::>::�::�:�:;::'•;::<
Gtias-I 3535- VW TOI
County Parcel Identification No.(PIN) :l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one latilong is sufficient) Q Iy 22.Cer nation:
95 9 N Vl.. li555 'fir
6.Is(are)the well(s):MPermanent or [ITemporary SigriaL.4 of Certified well Contractor Date J
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: DYes or [@No with 15A NCAC 02C.0100 or 1SA 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 421 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
a
9.Total well depth below land surface: "1 go (fr) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: gS (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
rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rY 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) Method of test: A r 24c,For Water Supply&Injection 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 t3W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016