GW1-2023-02530_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GIN t0-_,WATERZONES"• :' ,. I:�.
FROM TO DESCRIPTION
We o ac ,Name ft ft.
-�4 -A
ft ft
NC Well Contractor Certification Number 15.ODTER:Ce1$ING foc multi=ease`d:Wen':OR IIINER if:a"livable:a ct F- x=:
Morgan Well &Pump, INC FROM To DIAMETER THICIQQFSS MATERIAL
ft Ik ft 6-Ile m' I dr2l pvc
Company Name ;-:. •• !;; .=Y _'- =
r�_ 1"GINNERCASINGOR:TUBING e'otfieimaI:cIii5—a ci'o .�^�-
2.Well Construction Permit#:��i��r r FROM TO DIAMETER TffiCENESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): it ft in.
Water Supply Well: F1172OM.`SCREEN's'.k�'
T I DIAMETER.II SLOTSIZEI TBICENFSS- -1 MATERIAL,-
_I Agricultural Ll Municipal/Public ft ft. in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g ft, in.
Industrial/Commercial DResidential Water Supply(shared) 28;'GROUTS«'
EE Irrigation FROM TO :MATERIAL: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft hentonite poured
_!Monitoring DRecovery ft ft.
Injection Well: ft. ft
Aquifer Recharge n Groundwater Remediation
73 Q�� ]9 SAND7GRi1VII;�P.ACFG
Aquifer Storage and Recovery OSalinity Barrier FROM ft
MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage ftft.
J Experimental Technology )Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer -20.'MIEMM-ZG O.G'attiicli;iiddrh'onaI heeEs if$eiders' ";='
FROM TO DESCRIPTION color,hardness,soiUmck e, size,eta)
i Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) ft 15 ft
4.Date Well(s)Completed: 2. aZ Well ID# `� ft. 3� ft
ft ft '
Sa.Well Location: 50
r:^ LES � ft ft
a ,•Facility/Owner Name Facility ID#(�le) ft ft
ft. ft
�O
///Physical Address,City,and Zip ft. ft n
:iZY',RF.MARTCG:_.' -_ - = - _ _•_. `-'. _ _ i^ .'tsr`�C- r"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (� t
2(if well field,one lat/long is sufficient) 22.Cer',cation:
a N d�r���ic W
6.Is(are)the well(s)JNPermanent or ©Il Temporary
Si d o Certifie Well Contractor Daf
By tin t is form,I hereby certify that the well(s)was(were)constructed in,accordance
7.Is this a repair to an existing well: M
7 Yes or WKNo with 15ANCAC 02C.0100 or 15ANCAC 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 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: (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 a()200'and 2@100) construction to the following:
10.Static water level below top of casing: Lk o (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) k C a.� Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
n� the address(es) above, also submit'one copy of this form within 30 days of
granulated chicane 24b corn letion of well construction to the county health department of the county
13b.Disinfection type: Amount: P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016