GW1--03016_Well Construction - GW1_20230306

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Well Co rName FROM TO - DESCRIPTION
ft. ft.
� ft. ft.
NC Well Contractor-Certification Number
15;OUTER{CASING foi:mulhcase'diwells;ORLINER rf'a`bcable
Morgan Well &Pump, INC FROM To DIAMETER THICKNESS MATERIAL
1 ft "ft' 61/8 in' sd21 pvc
Company Name _
p y �O U��� ,,16S71VNER'CASINGORTIIBINI eotbermaldosedloo
2.Well Construction Permit#: "III 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.
.y
Water Supply Well: . FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
-'Agricultural IJ Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) @lResidential Water Supply(single) g, ft qm
__�Industrial/Commercial Residential Water Supply(shared) ;- -
is..cxonr_ . - -
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
`_Monitoring []Recovery ft. ft
Injection Well:
_ ft. ft
Aquifer Recharge [)Groundwater Remediation
.19.=SAND/GRe1VEL:PACFC'
Aquifer Storage and Recovery if iWik life
Salim Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage f—Ilt ft
Experimental Techn&gy Subsidence Control ft ft
Geothermal(Closed Loop) Tracer '120 DRILI3NGLOG sttieb idditionilsheets:ifnecess
C Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness saillrack a size,etc.
- — ft. ft
4.Date Well(s)Completed a 12Z Well ID# It. S It p(
5a.Well Location: ft. ft. X is
ft ft. --
Facility/Owner Name Facility ID#(if applicable)�e ft ft. G 3
�1-0 �S�b.Y,, ��_____ vW`� n VI[ ft. ft.
P ical Address,
City,and Zip j ft ft
V� �2I:`RElIIARKS .' _.i
County Parcel Identification No.(PIN) 0_1
5b.L'atitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) J'�Q^ 22. zrtificalion:--�
S, �to �O G 0 a� W N
6.Is(are)the well(s)�IXJ Permanent or OTemporary Si a Certified Well Contractor Da
By tt
s ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis 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 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-33@@2000'and 2@100D construction to the following:
10.Static water level below top of casing: t�V ` (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
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
pp ai
r pressure 24c.For Water SunDly&Iniection Wells: hi addition to sending 13a.Yield(gpm) L� Method of test: g the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: �3(00,7, completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016