GW1-2023-02531_Well Construction - GW1_20230406

' ��_ ; Frin'f Form;• '
WELL CONSTRUCTION RECORD (GA-1) For Internal Use Only:
1.Well Contractor Information:
14.:WAT_ IUZONES :;, :-PTIOz
FROM TO DESCRIPTION,
We[[(�o c rName ft. ft
NC Well Contractor Certification Number 15r:OUTEWCASIN foemrilti casedicvells OR IiINEIt iL'a"bcable: 5:
Morgan Well&Pump, INC FROM TO DIAMETER THICffiFISS MATERIAL
1 ft. 17S ft 61/8 m' sd21 pvc
Company Name l V
'^ _-16. INEFYCA51NG`OILTiJBING eothe'rmsi'cl5serl=lo5
(Jr FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#. it ft in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
17JSCREII$' c... .. c
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERTAr
- I Agricultural []Municipal/Public ft. ft in.
—')Geothermal(Heating/Cooling Supply) E§Residential Water Supply(single) g it• in.
J IudustriallCommercial E3Residential Water Supply(shared)
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINr
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring DJ Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.28AND/GRAVRL"PACK di`"licable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLA['FtvtF:ty't'METHOD
Aquifer Test [II Stormwater Drainage it ft.
J Experimental Technology �J li Subsidence Control it ft
-20.'DRILL-INGDO.G'atfsdraH•ditionaL"s`fie_ets
Geothermal(Closed Loop) Tracer "
FROM TO DESCRIPTION color,hardness,soil/rock e,grain size,etc,)
R Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) d ft ft-74 Y�
4.Date Well(s)Completed:7,• 4 Well ID# LS ft . ft
10 ft. � ft.
5a.Well Location:
bQoyl Mk
Fact #(iappcable) ft.
Facility/Owner ft- fft
OVO ft. ft.
F
ft w ft ..
Physical Address,City,and Zip
_ rvl<�eAFN 1) C 2023
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fi
el
d,
one lat/long is sufficient) 22 rtification:
3 5�1 N 06b �QL�2 W -G ��
6.Is(are)the well(s)4WPermauent• or ®J�Temporary
Si e o ertified Well Contractor Datei
By stgnin is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JpNo 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 ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 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@200'and 2@1009 construction to the following:
10.Static water level below top of casing: �� (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 Infection 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
1� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlodne Amount: E�- 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