GW1--03904_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
L57A` @gl� 14 WATEIt7ONES _
FROM TO µ DESCRIPTION
Well Contractor Name
ft ft
ft ft
NC Well Contractor Certification Number
,�,15,'OUTER CASING fof:mu`7tl,rased;v¢'ells
Morgan Well & Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL
1 ft ft 61/6 m' sd(11 pvc
Company Name 1 y
' I ^ //J� 16?INNERCiASING'_OR=TiiBING: 'eothermal`close3lo'o'
Z.Well Construction Permit#: ✓"�'��y �"�� ^I9���� EOM TO DIAI��TER THICKNESS µ MATERL4L`
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROSMG'RE�Op •• LDL4METER I SLOT SIZE I THICKNESS I MATERIAL•
J Agricultural J Municipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft
dustrial/Commercial _I Residential Water Supply shared - :.,
�In - PP Y(shared) '18::GRO,UT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non-Water Supply Well: o ft PO ft' bentonite poured
Monitoring DRecovery ft ft
Injection Well: ft ft.
Aquifer Recharge DGroundwater Remediation
;19%SANDZGRAVELTEACg'>fa
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
.Aquifer Test OStormwater Drainage ft ft
I Experimental Technology OJ Subsidence Control ft ft.
❑Geothermal(Closed Loop) `Tracer 20' RII,LIl�7GxO.G attach additional;sheetsiineceas. +':: z,:
J Geothermal(Heating/Cooling Return) _!Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness soWrock type,grain sae,etc.)
8 It, l0 ft eed r
4.Date Well(s)Completed: 5_ ZS Well ID# "Z ft 1 ft
5a.Well Location: j ft 51 ft. b6
Facility T//Owwner Name y L/ �I Facility ID#(if applicable) ft ft
7J� Li��/r, / I�• 'tJ ft ft
Physical Address,City,and
Zip ft ft.
[iCA*G
County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laatflong it GJs sufficient) O� 22.Certification:
G/�• °`t' Z_N �O. C `.� W 447�*21w.
1SiE#i1
6.Is(are)the well(s) !X'permanent or OTemporary Signature of Ce ed Well Contractor 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 15,4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and esplain the nature of the copy of this 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:' SUBMYrTAL INSTRUCTIONS
9.Total well depth below land surface: 261S (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: 40 (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,directpusb,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) L Method of test' air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
��i^� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: V� 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