GW1-2023-02218_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
<ri aQl 14:;FVATER'ZUNES:. ::_
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Well Contr for Name • FROM TO DESCRIPTION '
^ ft ft. I I
csco- ft ft 1
NC Well Contractor Certification Number
15:',OUTER CASING(for multt cased wells)ORI:INER(if ap livable) .,.
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. /f q ft 61/8 in' sd21 pvc
Company Name `1
fjjjj����� ;16: NNER`.CASING;OR�:TUBING,(geotliermal closed460)_;_ _-,.i., ._....._.
2.Well Construction Permit#: ��tp/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17rSGREEN .,, -'-'''''.1''
'
FROM 'TO DIAMETER SLOT SIZE• THICKNESS MATERIAL
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Agricultural •Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single) ft ft in.
'. Industrial/Commercial *IResidential Water Supply(shared)
>ls _ _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge D Groundwater Remediation
ai19i SAND/GRAVEL PACK(if applicable) .:
®*Aquifer Storage and Recovery C]SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Illi Aquifer Test 0 Stormwater Drainage ft. ft
•Experimental Technology D Subsidence Control ft. ft.
®I Geothermal(Closed Loop) DiTracer '.::20.DIIIIIINGs.ttiGUitliCh additionaFsheets.it:nec'essary) ,".' .•. .: '. , ..-,. ..:
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
a Geothermal(Heating/Cooling Return) i_f Other(explain under#21 Remarks) a ftp
ftBr f •a •
/4.Date Wells)Completed: -(p��. Well ID# 24ft ft. /3(2 e jfr)
/
5a.Well Location: ¶3 ft 5400 ft g Cw�
0
Me1 StraM {'b CCJ� ft ft. ji,14/>/6
ft ft. �, ; •- ... _,., i; ,
Facility/Owner Name -�/� �FQacility ID#(if applicable) -
�zL & -k 1 / I u ft ft. U ''-_ _ "r_,_.
Physical Address,City,and Zip / ft. ft MAR I\ t .1 L U L J
nL; ._ 21 REMARKS . _
County Parcel Identification No.(PIN) _ __,_, ,
• 5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certifica
�c5. 679ZS N . IGZ, W ?,`(6'
-23
6.Is(are)the well(s)MI Permanent or E3Temporary Signature of Certified a Contractor Date
. By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E Yes or INo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Li 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CtIO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@,22000'and 2@100') construction to the following:
CI
10.Static water level below top of casing: v (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 (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) � Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
I? ^ . the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: U 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