GW1--04208_Well Construction - GW1_20230706

Print Form.:.:_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C) 'ye- f14:WATERi7.O1VES' ;u ;;.,....r'- _,. i`-`
Name
��`—��' FROM TO DESCRIPTION
Well Contractor
ft ft
I
LIC4--A ft ft 1
NC Well Contractor Certification Number
i1501J1'P.R.CASING'(fo'r-multi cased`v¢eTs)UR`LaIER(i 'ap hcable)-5 . _.
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL •
1 ft L+5 ft 6 1/8 m sd21 pvc
Company Name / -_—
�7 16:IlVLIEIL`GASING OR'eTCTBING;(geo4hermal close�Yoop)
2.Well Construction Permit#: 13 a ` 7 FROM TO DIAMETER THICKNESS 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.
SCREEN =:
~Water Supply Well: FROM TO DIAMETER SLOT SIZEY THICKNESS MATERIAL
1 Agricultural I Municipal/Public ft ft. in.
[I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) lSi GROUT_ ''
�I Irrigation17:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
DitMonitoring DRecovery ft. ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEhYACK(ifapplic`able) "
IjAquifeI Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
•
Experimental Technology *Subsidence Control ft. ft.
BGeothermal(Closed Loop) (Tracer `20DRIILLTNGZO.G(attach addrironal<iheetsifnecessary}t
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(colordi.
,hardn/ess soillrocl type grain size,etc.)
(( 0 ft /�3 ft. gfi di 1/
4.Date Well(s)Completed: S c.. Well ID# 33 ft 1./(R ' it
/146
6 eV) �J/ J( ,
5a.Well Location: 23 • ft. ft.
fn` l(r ,,t/ e d ft. ft.
Facili�wnerrName Facility IDit(if applicable) ft ft
�J C Ok) 1 Id ft. ft. F^ + �"u'..a j't1't_�j i
C s nm. w..r A,..e t h ..,,,,r`
Physical Address,City,and Zip ft ft i'I I n nrjn
`�40� 2kiRFMA'RTCCF: .,. .. .-.._.'.:.-':; ::J L -. ,' 4 - .. _
L`J Parcel Identification No.(PIN) Inf.:::—..r. .,_'1 .o.". .. ?..3 'Jn:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DV10130
(if well field,ldd,one lattfloong is sufficient) 22.Certification' •
35.5 C4? N �()J.//l3t W 6`r L
6.Is(are)the well(s)MiPermanent or I Temporary Signature of e e ell Con or Date
By signing this form,I hereby cert(ly that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: :1)Yes or 'XI No 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 of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' f s 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@l00) construction to the following:
10.Static water level below top of casing: /J 6 ' (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 Injection 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 - - -
i13a.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
13b.Disinfection type: granulated chlorine / h Amount: to .5. 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