GW1-2023-02514_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Morgan
FROM TO DESCRIPTION
Well Contractor Name /1�71j ft. tel ft.
3572-A !� l ft. ft.
NC Well Contractor Certification Number .<.
�.15`':QUTER:CASING(farmu`1h-cased'well's)'ORILINER?Ctf`a cable -
Morgan Well & Pump, INC FROM TO DIAMETER THICIcivEss MATERIAL.
ft. 6 3 ft b il8 in- Sq2�(
Company Name :Y6;7NNEIZCA$ING,oR-TUBING `eothecmaLclosed-,Joo
FROM TO DIAMETER TLdICHNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)
ft. ft.
ft. ft in.
3.Well Use(check well use):
••,
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIUCKNESS MATERIAL
_.i Agricultural �Municipal/Public ft. ft. in.
a
Geothermal(Heating/Cooling Supply) Resitlential Water Supply(single) ft. ft. in.
_ Industrial/Commercial Residential Water Supply(shared) -fg,GROiIT•,
FROM TO MATERIAL, EMPLACEMENT METHOD&ALVLOUNT
gation
Non-Water Supply Well: p ft. Zp ft. bentonite poured
I Monitoring MIRecovery
Injection Well:
Aquifer Recharge [3 Groundwater Remediation •_'_
I.r11ROM
""N.W.GAquifer Storage and RecoverySalinity Barrier TO MATERIALEMPI 4CEMENTMETHOD
Stonnwater Draina ftAquifer Test � ge DSubsidence ControlftExperimental TechnologyL-- Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
Geothermal(Heating/Cooling Retum) OOther(explain under#21 Remarks) ft. 40 ft
4.Date Well(s)Completed: Well ID# (a ft. z ft. 9r61'JVL So,
enywi
YfiWl�
Sa.Well Location: ft. ft
Clawk— ft ft.
Facility ID# licable ifa ft. ft.
Facility/OwtnerNamlIe ( PP )
UtjW(Y �i -
ft.
Physical Address,City,and Zip ft.
IIME
{Il Al.V1 Ir15_1{4 .iv1.�..1 , V J-!` 1'l Ur$
County Parcel Identification No.(PIN) / J
v:'.vim...�'�.•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N St. 022 W
Signature Ce '&e ell Contractor Date
,XI
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: L_J Yes or XI No 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 remark 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: ,-600 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@`200'and 2@100') construction to the following:
10.Static water level below top of casing: 26 (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 /8 (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) �I Method of test: IY 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: chlorine Amount: 12-B?i completion of well construction to the county health department of the county
where constructed.