GW1-2023-02183_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C Morgan
kris Mo a 4�WA:F12:'•z0 S''::ii'•'•`:t�=:•;::;:;:(';`•:;',i-• ;;::�::::>;:;::i)6i'.;:::>::::::r..•>:•::r;:•:e::,
Well Contractor Name FROM TO DESCRIPTION
126 ft. ? ft.
3572-A -
I
NC Well Contractor Certification Number ft. ft.ft. ft in. "li;.>15"O.ilTElt'CttSING;(fo'r'mill[i=cssed';we1Ls}'012`•LTNER'(ifacafiie'(;�i> :;<�s>4".;Si':::;;;-:
Morgan Well &Pump, INC FROM TO DIAMETER THWENESS MATERLAL
Company Name �
((�� qq ::I6t:]NNERCASING;OR;TUBING �edt6ecmal'close3=lou' C ::=':':::r:
2.Well Construction Permit#: —[Q J 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Cz.e.UIC,County State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft, in.
::1 SCREEN ...........::iz.:.i:::::::::.::.'. :>;:.::t::::re:;•::::::4:?;tE: :sir::;r•::;;:t :'`'.:;i. `:;':::::::::;?::::::?:::::;::
Water Supply Well: 7
FROM TO DIA1tiIETER SLOT SIZE THICKNESS MATERLAE,
Agricultural ,pnicipal/Public it. ft in.[DM
Geothermal(Heating)Cooling Supply) E311esidential Water Supply(single) ft. ft. in.
industtiallCommercial []Residential Water Supply(shared)
_.. Irri ation . FROM TO MA=AL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring DRegovery ft. ft
Injection Well:
_ ft; ft.
Aquifer Recharge ElGroundwater Remediation ::.•...::...
_ _ ;::19::5iYND/GI2AT!.ELIFACK'iE'a 'licable"_�:;7:::: ?:`:�s;:; `;!: '::::;:t::_:5i;:•::':;::F�.t:::::t:::;
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EI4iPLACEl�fENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20 bRIIiITNGTOG'(attactiaddiiioual'stieets.iEnecess '.}:i;:<.'`:.;;?::::::;;::_<z:s;:;:;',f:: is'
FROM TO DESCRiPTiON(color,hardness,sail/rack S in size,etc.)
BGeothermal(FleatinglCoofing Return) Other(explain under�21 Remarks)
ft 9S rt. Gt
4.Date Well(s)Completed: Z ZD 23 Well ID# ft 6 5 ft. vQ
Sa.Well Location: ,./� ft. ft
2tmw,m}�l rya% ft. ft.
Facility/Own N(a�me ( �(� 1Facility DD#(if applicable) ft. ft.
3536 N°��'fW L Dy% �O�j 1OltlA,NL 2$ , ft. ft. - -
Physical Address,City,and Zip ft. ft n P ({a
Mk I22<C::::::;:::t<:::2::�::::::::?::�::: �:�i�r:.':::':4::::.':z.':�:.:':::t-'::;:'::Er<`:::5::.;:;':t:;•.'::.':::::��.:�;i::e:.t;:::�:t.:.�;::::;
County Parcel Identification No.(PIN)
1.1.0 .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Cer r ati0
55.N b 3 N S I- 110 W 23
6.Is(are)the well(s)oPermanent or EITemporary Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
a I
7.Is this repair to an existing well: E)Yes or E No with 15A NCAC 02C.0100 or 15A NCAC D2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explohl 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: I6 S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@a 200'and 2«100) construction to the following:
10.Static water level below top of casing: S (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/$ (in.) 24b.For Injection 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
13a.Yield(gpm) 19 Method of test: Air- 24c. For Water Supply&Injection Wells: In addition to sending the form to
chlorine �7
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_ (QZ 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 2-22-20 t 6