GW1-2023-02500_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
G�
WATER:ZONES.�--F?"r ::
FROM TO 'DESCRIPTION.
We o c rName ft ft.
14`,2—A ft ft.
NC Well Contractor Certification Number 15:`.OUTER;CASING foemulhcased wells:OR=-)7NER ifa"licable {;:<_t':; `r
Morgan Well &Pump, INC FROM TO DIAMETEM "THICKNESS MATERIAL
1 ft ft. 61/8 in. sdr11 pvc
Company Name AS NNRC' GDtTUBING e ithersclos&I-I6b _-- C
2.Well Construction Permit#: v�r FROM TO DIAMETER TEaCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft ft in.
1 '17:SCREEN.
Water Su
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATF,RTAT•
Agricultural []Muuicipal/Public ft ft.
:J Geothermal(Heating/Cooling Supply) @IResidential Water Supply(single) ft. ft. I in.
Residential Water Supply shared
_Industria]/Commercial -
-- PPY 18:GROUT'�
hri ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' bentonite poured
Monitoring JDRecovery ft ft.
Injection Well: ft ft.
f Aquifer Recharge 0 Groundwater Remediation
�- s.19:•SAND/GRAVEhPACK
_ Aquifer Storage and Recovery 0SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
3,Aquifer Test [3Stormwater Drainage ft ft.
J erimental Technology Control ft. ft
Exp
Geothermal(Closed Loop) I©�ITracer 20.DR]LLIl�TGS O.G:'attsdrad'dition`aFsheets if riecess`"' '' ' ' '--;'="
FROM TO DESCRIPTION color,hardness,soiltrock e, size,etc.)
I=i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) b ft ft. A—
IS
Date Well(s)Completed. �Well ID# ft. ft.
ft ft
fi5a.AW`erll Location 7-
V VW%A cc ft ft. '
Facility 2023
/Owner Name Q P� Facility ID#(i applicablle)) °�p ft.ft ft
�i V'b�JA L N��6)`� ►6 IL ft. APR V �?
Ph icaI Address,City,and Zip ft ft _ I
�'s�,�,�,�.���p ill i+_+i�:' ��l r� '
��JIA��M •- 5 A `.21RF.MARKR'-•'- - - _ - - _ -- "C.ji '_.�4," -—_ .
CDs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.CCe)rtification:
('1
6.Is(are)the well(s)iMPermanent or Temporary
Si f Certified Well Contractor Dates
B i in this form,I hereby certify that the well(s)was(were)constructed in accordance
Yes or No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction'Standards and that a
7.Is this a repair to an existing well
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 ifnecessary.
drilled:' SUBMYI"PAL INSTRUCTIONS
9.Total well depth below land surface: 360 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Iist all depths if different(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: 46 (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 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
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:
granulated chlorine Amount: completion of well construction to the county health department of the county
�®Z. P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016