GW1--03023_Well Construction - GW1_20230306

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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FR M TO I DESCRIPTION
Well Contractor Name
4550-A to
`
ft. ft
NC Well Contractor Certification Number �'.w QUTER:@ASING foc`mnlIf cased wells QRLINER"if a` 'kible u•
Morgan Well &Pump, INC FROM To DIAMETER in. V THICKNESS MATERIAL
ft. 6
Com an Name
ft
P Y ���-O^����- 1�gN�l -16>INNER;t:?iSINGA]Y:TUBING: "eotherm"al:elosedloo
2.Well Construction Permit#: ( FROM I TO DIAMETER THICKNESS V MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft ft rn.
3.Well Use(check well use): ft ft rn
_17 SCREEN -.::<,_: :. _- ..• .-
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS ~ MA TAT,
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) DDResidential Water Supply(single) ft. ft
Industrial/Commercial DResidential Water Supply(shared) _
s 18:GROUT.;
Irri ation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: ft. ft. i V
Monitoring DRecovery ft ft.
Injection Well:
it. ft
Aquifer Recharge i.._ Groundwater Remediation
�I9FSAND/GRAVEIYACK`rf a'"licalile_ _ _ = - -
Aquifer Storage and Recovery L_I Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Ji Experimental Technology E3Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 'tm-DRILLIlVG'EOG attaciiad'ditionalsli`eets'ifnecess _
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM To DESCRIPTION rotor,hardness soil/rock a size etc.
Oft. yft. ��r ,
4.Date Well(s)Completed. Well ID# lJ ft. Sj ft.
Sa',.Well Location: s0 ft It.
y�J
Ntc�_ /�nd ft. ft ✓L �JCC�vR•S2
Facility/Owner Name , ` Facility ID#(if1appplicable) ft ft. q f �
3 2I 1 C�YY1 �e�t� uGt 1� ft ft I_ -J.
Physical Address,City,and Zip I`c�2 ft ft i i, b , d
cCl (^'�a 6(� ���� M1�7(Y ZI:,..REMARKS. A 4
I i ij ZU13
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3(ifell field o e lat/lon is sufficient) q� 22.Certification:
N ven
6.Is(are)the well(s) ermanent or 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: i_!Yes or D(No with 15ANCAC 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: ., �16b
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'andd22@100) construction to the following:
10.Static water level below top of casing: (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: f 7' 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: II �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:A r 4 CVJ5''F-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
AA the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C C4 n-1 ar Amount: I b Pi� completion of well construction to the county health department of the county
where constmcted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016