GW1-2023-02489_Well Construction - GW1_20230406

Print Form -
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Contract rName
ft. ft
ft ft
NC Well Contractor Certification Number
;15:OU1'ER;GASIIVG for.mulh casedwells:OR-LINER tf,a hcable :�'� N �
Morgan Well &Pump, INC FROM TO DIAMETER TDIC10ESS MATERIAL
1 ft t 61/8 m' sdr2l pvc
Company Name
J E16 INNEF CASINQORT[7BING;`eothermal:close�7oo s
2.Well Construction Permit#: o FROM TO DIAMETER THICHNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in
Water Supply Well: FROM TOTO~y' DIAMETER{ SLOT SIZE4 V TffiCKNESS 4 MATERIAL v
_i Agricultural �Municipa]/Public ft. ft. in.
:)Geothermal eatin Coolin Supply) (single) ft. ft rn
Industrial/Commercial g PP Y) (shared)
Residential Water Supply
aResidential Water Supply GROIIT.__.:_;".
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 Groundwater Remediation
-I9'SAND/GRAVEL PACK(iE licabl"e
Aquifer Storage and Recovery _;Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©I'Stormwater Drainage ft ft.
]Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer `2D'DRII L TG;I OG attach additio'riul'sheets"if necessa :x- -_
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness satllrock type,ygrain size,eta
ft (! ft lal�2 t
4.Date Well(s)Completed: ~� ~�J Well ID# Q ft D ft QI f r
5a.Well Location: 19 U
ft ft rwl-
LI LAEdn M 11�/ oft 5 ft. 1 b V
Facility/Owner Name Facility ID#(if applicable) ft ft
L/ /� it. ft -
r
Physical Address,City,and Zip ft ft
2V W`rtr 1 21:RF.MARKC _ PUXy `.. b' 3,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tfwell field,one lat/lon is sufficient
(• d, g ) 22.Certification:
N�O� W v 17,2,-2�
6.Is(are)the well(s) U Permanent or OTemporary Signat6e4ftertified Well C c or 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: I_ Yes or MNo with 15A NCAC 02C.0100 or 15A 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#21 remarks section or on the back of this farm. 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:' (r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: It7 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent lexampl�@20200-''and 2@100D construction to the following:
10.Static water level below top of casing: 'AD (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 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
air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
7 the address(es) above, also submit one copy of this form within 30 days of
13b.•Disinfection type: granulated chlorine Amount: Q(� 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