GW1--03897_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infor lion:
�e A
y V wATERzOi9Es
FROM TO DESCRIPTION
Well Contractor Name
4 ^� ft. ft.
sA
c`J ft. ft. I
NC Well Contractor Certification Number 15 OFJTER'CASILVG fo miilaiase3iveIls;ORIdNEIt if a hcable
Morgan Well &Pump, INC FROM To DL4METER TfficlsTrEss MATERIAL
1 ft ft 1 61/8 m' sdf21 live
Company Name
�/yA ,16INNER:Gi15TNG�ORTI7BING.`"eotheririslclosetiloo :b
2.Well Construction Permit#: �L (S✓( �—' Y {D In/ FROM TO DIAMETE I T'aIICKNEss 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.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft in.
_ Geothermal(Heating/Cooling Supply) JEResidential Water Supply(single) ft ft.
Industrial/Commercial I_I Residential Water Supply(shared) 18`GRODT r...
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
Recharge
ft.
Aquifer charge [)Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD v
Aquifer Test ElStor awater Drainage ft ft
I Experimental Technology OSubsideuce Control ft ft
Eli Geothermal(Closed Loop) OTracer 20; RILtiINGZOG=atiacliaddr4onaI sheetsaf recess
FROM TO DESCRIPTION color,hardness sod/rock e, size etc. "
Geothermal(Heating/Cooling Return) 7-_I Other(explain under#21 Remarks) ,rl ft L O ft.
4.Date Well(s)Completed: / L7 Well ID# VO ft- o it.
a �/
Sa.Well Location: O ft p ft re f 6 %1
ft ft-
Facility/Owner
^►
Name Facility ID#(if applicable) it. ft
y/�Lr' l �� ft ft 2023
Physical Address,City,and Zip ft ft
�/dct _
�Z1 REM�ARICSr'-:_ ��..,.c _.....• - ��
DWQiSOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one.lat(longis sufficient) 22.Certifica'on:
3S , 7_41/? N 7:2 W
6.Is(are)the wells) IX permanent or []Temporary Signature of Certified Well dimtractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 'Xi No with 15A NCAC 02C.0100 or 15.4 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Zia (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20TT0'and 2@100D construction to the following:
10.Static water level below top of casing: Y 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 2769 9-1 63 6
�O air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: Z 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