GW1-2023-02488_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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� Nj ,14.:.wAxElzolvEs<`�
FROM TO � DESCRIPTION _
Well Contractor Ame
4�4rr '^ ft. ft l� /�L(l ft. ft
NC Well Contractor Certification Number :15:;OUTER:CASING fo'iniilti=cos"ed;wells"OR LINER.tf'a'`livable _
Morgan Well &Pump, INC FROM To DIAMETER THICKNESS MATERIAL
1 ft ( ft 61/8 m' sd21 pvc-
CompanyName
36 INNER:CASING;ORTIIBING:`eothermal dosed loo
2.Well Construction Permit#: FROM To DIAMETER TffiCKNESS 3i1- MATERIAL`~
List all applicable well construction permits(i.e.UIC,County, tate,Variance,etc.) ft. ft in•
3.Well Use(check well use): ft ft to
Water Supply ,17 SCREEft.._.:: " ..a".` � ,�! ^` -� `= i__._ ,__ , �_ i`r• ._�.
PP Y Well: FROM TO DIAMETER } SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) GAOUI, ?,:L
hTi ation 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 _
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMT LACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology Subsidence Control % ft
Geothermal(Closed Loop) QlTracer 20:=DRILtiING'T OG attac]i'additionaI sheets if'necess it__
Geothermal(Heating/Cooling Return) !Other(explain FROM TO DESCRIPTION color,hardness soil/rock a size,etc.)
- lain under#21 Remarks) ft ft
4.Date Well(s)Completed:1��ell EM it ft
5a.Well Location: it ft
Nr r ft ft r C
Facility/Owner Name Facility ID#(if applicable) ft ft J
Physical Ads mess,,�C�ity/,�and Zip ft. ft k tis'{ ' y �; M
�0 V Vt/tf 1 REMARKSi; -_ : UZJ
County PazcelIdentificationNo.(PIN) 21i
APR_ J 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.0�tifitin: vtt+���'%`�'•�"
2Iq N �C� I ZC�� W _1
6.Is(are)the well(s)JMPermanent or OTemporary Si&6re of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: Dyes or IX'No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 JFell Construction Standards and that a
Ifthis 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
9.Total well depth below land surface: V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 20 _(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) So Method of test air pressure 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: granulated chlorine Amount: 4
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