GW1-2023-02509_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
..14�:WATEIRZONES;
FROM TO DESCRIPTION'
We o c rName ft ft.
ft ft
NC Well Contractor Certification Number
15:_OUTER"CASING foxmnlh casedweIls:ORL-INER,rf.a hcable ai_._ �:_"
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft ft 8 118 m• sdr21 pvc
Company Name m1$bINNEAGASINGOR'rTIJBING';eathermalilosedlao
2.Well Construction Permit#: FROM ft TO DIAMETER THICKNEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. in.
ft ft in.
3.Well Use(check well use): -
Water Supply Well: FROM TO DIAMETER SLOT SIZE i THICKNESS MATERIAL `t
i Agricultural LDJ Municipal/Public ft. ft i•
J Geothermal(Heatingicooling Supply) J@Resideritial Water Supply(single) ft ft in.
!_'Industdal/Commercial DResidential Water Supply(shared) 18:GROUT �� w: .x :- . - - -r-r•...::u; .r ';"
Lll atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
_ Monitoring (_ Recovery ft. ft
Injection Well: ft ft
Aquifer Recharge ( Groundwater Remediation
19 SAND/QZAVEI PACK'ita 'licatile .??
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMELACEMENTMETHOD
Aquifer Test Stormwater Drainage ft ft
1-I
J Experimental Technology [3Subsidence Control ft ft.
J Geothermal(Closed Loop) DTracer 20:DRII L'INTGI OG attach;iidditio"n'a151ieets;if'necessa
:.
FROM tT0JDE1CRIPTION color,hardness sod/mck e, size,etc.)
Geothermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) ft4.Date Well(s)Completed: J a� Well ID# 35 ft5a.Well Location: Sft yyt'L
Facility// erName __ ee ` Facility
yIID,,#I(if applicable)�/� a ft { YC.+{.y_
too-A *lb�tt' !_II® ���Ab�. YVV 2b y; do ft
ft ft
Physical Address,City,and Zip
r21;'RF.MARKC� 3`r
TN
County Parcel Identification No.(PE-1)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ift7C•,'r;::3 ;C;1 ?r,;,�,r;;,� of:a
(ifweell field,one laCt(long is sufficient) 22.Certification: r_i�„
6.Is(are)the well(s)JNPermanent or oTemporary
Si f Ce a Well Contractor Datk
JB ignrng this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or QlNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
this is a repair,fill out known well construction information and explain the nature of the copy ojthis record has been provided to the well owner.
If
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 if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2—CO —(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: qS (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
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 8Z completion of well construction.to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016