GW1-2023-02491_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan
FROM TO DESCRIPTION
Well Contractor Name a ft. It ft.
3572-A /7
ft. ft.
NC Well Contractor Certification Number 1,.f5 OUTER CASWGG 064inultr-6ase''d wells O_ RLINE1t i£a"'licable ` _
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS I MATERIAL
ft. `Q 8 ft. in.
Company Name ✓._ ;:. :,_
�7 /� t�6>TNNER(iASING.ORfiUBING''eottiermaL"closedloo'- � ..�:�.::':�:;:
2.Well Construction Permit#: 3 7 ` 6 q FROM To I DIAMETER THICKNMS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: �A S.Cl2EEN
PP Y FROM TO DIAMETER ISLOT SIZE THICKNESS I MATERIAL
:)Agricultural Mun' 'pal/Public ft. ft. in.
71 Eesidetial
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft.
Inds trial/Commercial Residential Water Supply(shared) ;,.
- s � PP ,.187:,tsROUT_ -
Irrigation FROM TO -I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft' bentonite poured
_i Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
_2 Aquifer Recharge rLJ1 Groundwater Remediation
Y9:S11ND7GRAVEL.PACK`d licable = �
Aquifer Storage and Recovery [2Salinity Barrier FROM TO MATERIAL J EMPLACEMENT METHOD
i Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 20rDRILLINGLOG(attaeli°a'd"dih5nahsfieets necessa•)`:._ss,:
FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,etc.)
_J Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) O ft. 66 ft. IGe_J
4.Date Wells)Completed: L Well ID# ft. ft. �"
5a.Well Location: 3 ft. ft. r
ft. ft.
Facility/O nerName Facility ID#(if applicable)
ZZ00LIM Au Ty 1 h' (�
Physical Address,City, d Zip 2 � ft. ft 7 0
APR 0.
QQ J 16CQ i <
_ ww� I 21:RIIILARKSt :_::,:rr _
County Parcel Identification No.(PIN) 1f1 1 ,r r l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'fication:
N 4b,5g5�5 W
6.Is(are)the wells) ,X!Permanent or OTemporary Siginifure of CertifiecrWell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or XI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this iss 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:' n ,,, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: So (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-n3@200'and 2@I00') construction to the following:
10.Static water Ievel below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifvvater level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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: A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:L,*,r 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: chlorine Amount: 7(12 completion of well construction to the county health department of the county
where constructed.