GW1--03249_Well Construction - GW1_20230511

Print Form;•
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
:;14.WATERZONESi::_�,:_:; ::,=�``a_'.:.:>.: ::.:.:.:......:::FROM TO DESCRIPTION
We o ac rName ft. ft.
_�421—A ft ft.
NC Well Contractor Certification Number
:15::OUlERCASING-formniti=casedweIls ORISNER if:a hcable;';;=,:•a -:. °s'=
Morgan Well &Pump, INC FROM TO DIAMETER TEiCKNESS MArFurAL-
1 ft ft 61/8 in. sd21 pvc
Company Name r= r
• �� '.-I6INNERCASIN&ORTUBING': eotlietmaIelose3loo :_
2.Well Construction Permit#: FROM TO DIAMETER THICENESS 'r MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,r arlance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft in.
'17:ISCREEN > '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public
J Geothermal(Heating/Cooling Supply) J Residential Water Supply(single) ft ft.
Industrial/Commercial DResidential Water Supply(shared)
�!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft' bentonite poured
r.Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
:—]Aquifer Recharge Groundwater Remediation
19rSAND/GRAVEhPACK if a"
11 Aquifer Storage and Recovery �J(Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test - []Stormwater Drainage ft ft.
J Experimental Technology MSubsidence Control ft. ft
J Geothermal(Closed Loop) IJ Tracer 20:DRILLIl\rGT OG'atGicli additionaIsheets if riecess': ::z:ss _
FROM TO DESCRIPTION color,hardness,soiUrock •e,g r size,etc.)
_i Geothermal(Heating/Cooling Retain) r Other(explain under#21 Remarks) 0 ft. -o ft
4.Date Well(s)Completed f Well ID# �® ft. ft
5 .Well Location: � ft � ft. y�.' •.;--?;r.���``'�; `�•�,I
ft. fts.
J
Facility/Owner Name Facility ID#(if applicable) tz:
ft.
^ ft. 'y';'l i�f:r� � •s� t0
! "v;.
Physical Address,Ci lo—
w 7ty,and rp ft. ft end a
'Y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe�ll field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)�Permanent or Temporary si of Certified Well Contractor Date
By el
his form,I hereby certify that the well(s)was(were)constructed in,accordance
7.Is this a repair t0 an existing well: DYes or QlNo with 15A NCAC 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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: UA (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2@100� construction to the following:
10.Static water level below top of casing: L� (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
13a.Yield(gpm) Method of test- air pressure 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
granulated chlorine com letion of well construction to the county health department of the county
13b.Disinfection type: Amount: 4 CAS P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016