GW1-2023-02486_Well Construction - GW1_20230406

- I
• �.-_.-:Prfnt Form;;`::.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
,114 WATERZONES:FROM TO DESCRIPTION
!We a ac r Name ft ft
ft
NC Well Contractor Certification Number "" "
335.`OUTE]iiCASING:£demulhcas0d.well's OR7fiTTER if'a 7icable
Morgan Well&Pump, INC FROM TO DIAMETER ' THICKNESS I MATERIAL-
1 ft ft 61/8 m' I d,21 pvc
Company Name
� ��� i'1'6`INNERCABING',OFLTUBING; eotliermal''closed l66
Z.Well Construction Permit#: FROM TO DIAMETER TMCR'NESS y w MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
ft ft in.
3.Well Use(check well use):
:1Z.:SCREEN
Water Supply Well: FROM To l DIAMETER l SLOT SIZEt THICKNESS MATERIAL.
Agricultural MMunicipal/Public ft ft in
.DJ Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) g, ft. in.
Industdal/Commercial Residential Water Supply(shared) - - ,
>18iiGROUT _ `:;; ::'; ;.';c_'.';
—�i hri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
_Monitoring n
J Recovery ft ft.
Injection Well: ft ft
Aquifer Recharge (-J Groundwater Remediation
:.19::SAND7GRA`4'EIs'P�E&`if�a"livable':'�:`. ::.`- % S':r,'.r,:ac_�:,;-:.,:.:,'.:=�.r__
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
J Experimental Technology Subsidence Control ft %
!Geothermal(Closed Loop) MTracer 20'DRILLIl�TGEO,G'a'ttschadditionaI'slieets
FROM TO DESCRIPTION(color,hardnevs,soil/rock type, size,etc.
71 Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) � ft. 10 ft
4.Date Well(s)Completed:3 r—! Well ID# ft. ft.
()1 ft f-
5a.Well Location: i�// u
Gar
r��Comm °."'� � ft �ft.
Facility/Owner Name Facility ID#(if applicable) /} ft ft.
ft ft APR 0 U 2023
Physical Address,City,and Zip (�C
�� �� ��—W�J 21iRF.MARKR�:. .__ c_ _,. ',"....`-.. •.;r. a4
in;.=ie:, 'gin a,_N :"•:l '°r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifcation:
.� N4do.% %2o W
6.Is(are)the well(s)JIPermanent or OJ Temporary'
Signatur f ed Well Contractor to
By si ng th' rm,I hereby certify that the wells)was(were)constructed in•accordance
7.is this a repair to an existing well: nYes or JFNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction'Standards and that a
Ifthis is a repair,ill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: �Q0 (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@200'and 2@100D construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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:
(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&Iniection'Wells: In addition to sending the form to
e� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion granulated chlorine L,®'Z. 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