GW1--03014_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1�` d `� _
.;14:WATER'ZONES. _._1 __ .Vr,w
Well ontractorName FROM TO DESCRIPTION
ft. ft.
�.. � ft ft
NC Well Contractor Certification Number „15.°OUTER=CASING`f6tmulti rased'we]Is'.OR•IINER d'a hcable:_.
Morgan Well &Pump, INC FROM T DIAMETER THICKNESS MATERIAL
1 ft, ft. 61/8 m; sd,21 pvc
Company Name r
s� �j ) M.'INNERCASING'ORTUBING 'eottieimsl'closedloo
2.Well Construction Permit#: 2W73—•' nal g FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17E:8 CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL -'
_i Agricultural DMunicipal/Public ft. ft.
in
FROM
(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in
_ Industrial/Commercial DResidential Water Supply(shared) 18:,GROIIT '
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ti ft 20 ft• bentonite poured
Monitoring DRecovery it. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
��19:'SAiVD1GRAVELPACK`rfa"�licable •_ -.' -'
Aquifer Storage and Recovery QlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Y
—Aquifer Test =;Stormwater Drainage ft. ft.
i_i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 203'DRILLING L`OG;ettac)i additibnal's`heets if:iiecess "-' _
FROM TO DESCRIPTION(color ha ,sailfrock e, size,eta)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D ft. ® ft.
4.Date Well(s)Completed: Z-� Well ID# 0 ft v ft 611.
Sa.Well Location: 0 ft. ft. a�
ft ft i
Facility/Owner
Name /�/(� /�G / /r,� Facility M#(if applicable) ft ft
S_1 L.fto ��V —1 J yy�l V� Cd ft ft
Physical Address,City,and Zip ft ft.
GabGW l"U5 2LREMARKS, c s
County Parcel Identification No.(PIN) tn`.r. "n, �r ^"•7(i3 it
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long/is sufficient) �A —7� 22.jCeArtlifica'oN97.6 O q?3 W
6.Is(are)the well(s) iX Permanent or OTemporary SigKire of Certified 7ell 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 MNo 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 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 ifdii ferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: `i b (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 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) Ld Method of test: air pressure 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: granulated chlorine Amount: l 7 �Z' 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