GW1--03231_Well Construction - GW1_20230511

Pri;ntForm :
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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OM I TO DESCRIPTION
Well Contractor Name
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4550-A
it ft ,
NC Well Contractor Certification Number
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Morgan Well &Pump, INC FROM TO DIAMETER 1 TBICKNESS MATERIAL
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Company Name � � OQ � /l� ;76IIVI�TER:C-AS11VG'OR�TQBING;eottiernial-c"losed�ho t�`�. .M.__'
2.Well Construction Permit#: l/i I FROM To DIAMETER TBICKNESS MATERIAI.
List all applicable well construction permits(i.e.TC,County,State,Yariance,etc.) ft ft in.
3.Well Use(check well use): it ft in.
Water.Supply Well: ihi::S.CREEIT��`tip::::�-:}:��r-_'-;;:_..-'f•---,�_�.:.�.._ t_ Y+. '� i '=:
�,y FROM TO DIAMETER SLOT SIZE TffiCIQVESS MATERIAL
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Agricultural Municipal/Public ft ft in.
_-i Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft. ft.
i J Industrial/Commercial _i Residential Water Supply shared -
Irri ation FROM TO r MATERIAL EMPLACEMENT NXTHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Uu
[]Monitoring i=)Recovery ft. ft.
Injection Well:
ft ft
J Aquifer Recharge Groundwater Remediation
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I Aquifer Storage and Recovery D Salinity B arrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ©1 IStormwater Drainage ft ft
[I Experimental Technology E3Subsidence Control
ft. ft
Geothermal(Closed Loop) ]Tracer ;20:IiI2IIiLIl�GOG=atfacli'adaitiorial:'sheelseceas" i :wf--: -_ r= ?=,:
_I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRD ON(color,hardness,soil/ %
V ft -,
4.Date Well(s)Completed: ' 'Z1J Well ID# ft ft rPmc;5 i'1=.,g J0
d
5 Well Location: ft ft
ft. ft �q
Facility/Owner Name V Facility ID#(if applicable)
S'99>
Physica d/dress,City,and Zip ft
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well 3S field, lat/long is sufficient) 22.Certification:
d,l f 7 N yo ,67a.97 w , ��'
6.Is(are)the well(s) Permauent or OTemporary Signature of Certified Well Contractor Dat
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: [)Yes or MI (]No 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 421 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
S.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: L� (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@1000 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 Injection Wells: In addition to sending the form to the address in 24a
�S, 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 2 769 9-1 63 6
13a.Yield(gpm) Method of test:Ar ?(V-Lf`-'(c- 24c.For Water Supply&Injection 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:GPI"a n A aC Amount: b 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