GW1-2023-02521_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only: j
1.Well Contractor Information:
Chris Morgan4:.wnzolvEs
FROM TO DESCRIPTION
Well Contractor Name ft.
3572-A /GV fc. I ft.
NC Well Contractor Certification Number
15e:O.U.TE117cX (fdn.mnlh cssed;welIs OR 7sIl�III;<tf:a""'licable
Morgan Well &Pump, INC FROM TO DIAMETER I THICKNESS Mp IA ATERL
in. SK21 eve,
Company Name •!
�' r T6INNERSING;ORTLTBING `eotheemal7osedloo
2.Well Construction Permit#: r .I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 'n
3.Well Use(check well use): ft. ft. in. ,
=iITSCREEN;..:... .... _ �.>;•�;d'=,;;i,_:.� : .?:-:z �. , , ..
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural MMunicipal/Public ft. I
I Geothermal(Heating/Cooling Supply) MLIk4sidential Water Supply(single) ft. ft. in.
Industrial/Commercial
U Residential Water Supply(shared) t,- _- = _ '=?* :rF= °•` Y�'='P
In
-!Irrigation FROM TO j MATERL4, EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: o ft. pp ft. bentonite poured
Monitoring Recovery
Injection Well: ft. ft.
_i Aquifer Recharge )Groundwater Remediation jq SAID7GI2�VFL PACIC(ia licatihe 4 r `t r `
_i Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [I Stonnwater Drainage
—:'Experimental Technology DSubsidence Control
Geothermal(Closed Loop) EITracer 20iDRILIINGT OG(atfac6 ad"ditional sheets`£necess"");S 3v
FROM TO DESCRIPTION(color,hardness,soiUrock e, 1n size,eta)
_'.Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft 40 ft.
4.Date Well(s)Completed: 2-2A'2 Well iD# 1 It. 1(.6 ft. d'JW qut�
6( "' W ft' R
Sa.Well Location: 76V V•1'
ft. ft.
ft. ft. �' 17a-•r`^•,
Facility/Owner Name
/ ! Facility ID#(if applicable)
Y s
Physical Address,City,and Zip ft. ft.
21-REWARKC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.rCtifi atio
-3S.3ggq N f l-' U W 3 Zy-7-9
6.Is(are)the well(s) X!Permanent or OTemporary Signature of Certified Well Contractor 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: Dyes or L>JV1 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 421 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:-'I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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: Z5 (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 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
[ff the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: chlorine Amount: completion of well construction to the county health department of the county
where constructed.