GW1--03900_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�SeXUis�waT�i�Oi�s ,. _
Well ConhactorNam FROM TO DESCRIPTION
ft ft.
A ft ft
NC Well Contractor Certification Number w
:.13..,OII:TER;CtiSI1V.G formnlhcased�y¢ells O1tZINElt,tfa 7icahle:;;- -<"`
Morgan Well &Pump, INC FROM TO DIAMETER TEICIMSS MATERIAL
ft ft 61/8 in' sd2l pvc
Company Name _
�-0z 7v Z�—�� 16=INN_ER.0 GORTLTBIlYG 'e'ofhermal"c]n"sed7od `�
2.Well Construction Permit#: �9� FROM TO EDIAMETER THICKNESSMATERIAL <
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft M in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
FROM TO =,DIAMETER SLOT SIZE THICIQVESS MATERIAL
Agricultural [3Municipal/Public ft M in.
Geothermal(Heating/Cooling Supply) K Residential Water Supply(single) ft. ft.
_Industrial/Commercial DResidential Water Supply(shared)
r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
I_J Monitoring Recovery ft ft
Injection Well:
_ ft ft
Aquifer Recharge DGroundwater Remediation
• t 19s$AND%GR:9.VEl:EACK if a'•-]i"c3lile � -: ._>`_•,:_.�:��.'. .;._.. _ :... ..:;�s
�I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer r20 DRILLINGI O.G'atfaadfiiBo`nal;sheetsinecess `'
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type sue,etc.)}
2 D ft 10 ft. W a i(a, l
4.Date Well(s)Completed: Well lD# A O ft ft 5r' t(I r/-
5a.Well Location: ft. y ft' (0t/n
�v 1)cr+ LFx{1r ft ft
Facility/Owner
�Name Facility 1D#(if applicable) ft ft
3 ' One� �^
� /NUIJo,\ 12a• ft ft.
Physical Address,City,and Zip ft ft
ca-k �I 21 RT it A9zYCSh r __ il:.
County t� Parcel Identification No.(PIN) -
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
, . J V hry v 9 2023
675 N n
ZJ
6.Is(are)the well(s)J Permanent or ! I Temporary Signature of Certified We CA ractor 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• []Yes or 'XI No 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 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L/U� —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 7� (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) air pressure 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
Method of test: g
i s 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 of Environmental Quality-Division of Water Resources Revised 2-22-2016