GW1-2023-02529_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
al
1 Q(�A
FROM TO DESCRIPTION
Well Contractor Name
ft. ft
ft ft
NC Well Contractor Certification Number 15.'OUTER:CASING;(for multi-casediwells;UR•LINER rf:a lrcable
Morgan Well &Pump, INC FROM To DIAMETER TffiCIM- MATERIAL
1 ft ft 61/6 in' sd2l pvc
Company Name C �f �J ;16iIlVLgER;CASING'OR�TilBING; eotlierinal`clos`edloo v__ :; ;. ,..<�>,-';{`
2.Well Construction Permit#: v I y °' FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: st?REEN�o'_ i DIAMETER t SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public gFROM
ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft in,
Industrial/Commercial DResidential Water Supply(shared)IIri at10Il TO MATERIAL `EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
_;Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
�< -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft
-!Experimental Technology OSubsidence Control ft. ft.
L_ Geothermal(Closed Loop) (J Tracer ;2oltDRII31IlVG'LOG iittacliadditionsl's&eetsif iie`e'essa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color, ardness,soil/rock Ye~ size etc
2j O ft ft.
4.Date Well(s)Completed: r�7 S J Well ID# '0 ft 4 it. PYX /` 1
Sa.Well Location: ft '7 ft O f'CJ
' C� , act//b ft vo ft l /.
Facility/Owner Name FacilittyyID# rfapplicable) ft ft
ft. ft.
Physical Address,City,and Zip ft ft APR
D ,
C1tOW ba _ Il
'i:21�:REhIARxs..._:�, ....•-_..:..: .,: r ...: r:".� �, .. . �. ., �:: :
County Parcel IdenfificationNo.(PIN)
+J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification•
N -)
6.Is(are)the well(s)JMPermanent or i_._I Temporary 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: [)Yes or JNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:' 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 ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 30 (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
12.Well construction method:
rotary above, also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1 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
r/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 1 �!J ��' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016