GW1--03323_Well Construction - GW1_20230512

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
I.Well Contractor Information:
14.VITATERZONES
FROM TO DESCRIPTION
We on c rName ft. ft.
®4 L�" ft ft
NC Well Contractor Certification Number �,,15:OUTER CASING'fdc miilti eaced�wells OR LINER if a`"Iicable
Morgan Well &Pump, INC FROM To DLAMETER THICICNESS MATERAL-
1 ft ft 61/8 in. sd21 pvc
Company Name r
=16.3NNEWCASING_ORTUBING" edtheririalclose'd•Id"o
2.Well Construction Permit#:_SIA FROM TO DIAMETER TffiCENESS MATERIAL
List all applicable well construction permits�.e.UIC,County,State,Variance,etc.) ft. ft. in.
ft. it in•
3.Well Use(check well use):
'M'SCREEN
Water Supply Well: FROM TO J DIAMETER SLOT SIZE THICKNESS MATERIAL
:!)Agricultural n
JMunicipal/Public ft ft.
:]Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) g_ ft.
::Industrial/Commercial L_�Residential Water Supply(shared)
..-1s::GROUT"'-: .:.,<.['.�:'':`�:;"::':_-. `::`:.".::'`:.:..-.. "'-:.......: ._. - -_�
[-_:Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring _Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation .SAND7GRAVEL'PACK if a"hcable
_
I Aquifer Storage and Recovery OSalinity BarrierFROM TO MATERIAL EMPLACENT-METHOD
Aquifer Test [II Stormwater Drainage ft ME
ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20:DRffSIl$GI O.G'attadiadditidnaIah@ets ifriece5sa
FROM TO DESCRIPTION(color,hardness,soil/ruck type,.. .grain. size,etc.)
B Geothermal(Heating/Cooling`Return) _J Other(explain under#21 Remarks) 0 ft. ft.
119
bra-Ain Alleir
4.Date Well(s)Completed: I Well ID# Its ft.
30 fftt.
Sa.We Loca t q
C ft. ft.
-
Facility/0w;ZeY Name Facility ID#(ifapplicable) ft. ft. _z1
ft. ft.
C16 D MAY
'
Ph rcal Address,City, d Zip
it. ft.
�lR3r�@(0 Zl`:REl\SARKS':i-'•::. `:i. :::e: �
.. '
Parcel Identification No.(PIN)
County •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one late/llong is sufficient) �ry 22.C tification: rg
N ���� E� W J
6.Is(are)the well(s)APermanent or CJ Temporary Si42EiUfCeitified Well Contractor Dale t
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: rJYes or JJNo 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 ofthis 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:t 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-3(200'and 2@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: 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 SUP�Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) b 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: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016