GW1--04851_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
,i.,: ._
'.14:i:WATER•ZONES''.5r=ems_ y�>�;:•.a-;5._ _ .,.
FROM TO DESCRIPTION
Well C tra tor Name
ft ft
".5427---16 . ft ft
NC Well Contractor Certification Number t(15'QUTER GASING'(toirnulh=raserLwells)ORIJNER(it:ap'7icible) '_:; r t
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ft. 61/8 m' sdr21 pvc
Company Name , •, c---0): '.-
0 Ew o� `16''INNER C" GORTtJBING•(�eotHermal�clo'see ]oop)":`• ; . . -
2.Well Construction Permit#: \�(\ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(re.UIC,County,State,Variance,etc) ft ft in.
•
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM S ET pi "DIAMETER J SLOT SIZE THICKNESS MATERIAL •
a Agricultural J)Municipal/Public ft ft. in. .
. 1 Geothermal(Heating/Cooling Supply) INIResidential Water Supply(single) ft. ft. in.
"Industrial/Commercial . DResidential Water Supply(shared)
i Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
II pRecovery ft. ft.
Injection Well: ft. ft.
**Aquifer Recharge DGroundwater Remediation
i'19 SAND/GRAVEL PACK(rf;applscable)"t :'.:."�. . -"...
ØAquifer Storage and Recovery }ISalinityBarrier FROM TO - MATERIAL EMPLACEMENT METHOD
*Aquifer Test DiStormwater Drainage ft ft
Ii Experimental Technology Ell Subsidence Control ft. ft •
*Geothermal(Closed Loop) Tracer j 20 DRI Il!IG'LO,G(attach=additioniis$ee`ts'itneceieaiy)s:``.,VZ,:i`-."..":". - "-
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Il Geothermal(Heating/CoolingRetum) +c� Other(explain under#21 Remarks) to ft. (ll,r� ft. b , Al
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4.Date Well(s)Completed: d [ k 3 Well ID# 1 b ft '3 J ft'-1k rocAc
5a.Well Location: L 35 ft. 11 p ft �� n_,tfjo
S6L ft. l LJ J ft `l',,)1
Facility/Owner Name FacilityID#(if applicable) r,:( r. t A 7 f�,
yty PPR��' +) ft ft. -. - C Q
f `r �V o L1 i�►J S r' iCt t\\C !�` )-61 -' ft ft 'ter o v
Physical Address,City,and Zip ft. ft. JUL J.J 8 zo?3._
i 0
11 0 t 21i REMARKS`<
County . Parcel Identification No.(PIN) �• ,
v 4 4`Qt rL`€a
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field,)one laatt/_long is sufficient) `� 22 C cation:
35
..--2 i'l:/ _"'. _
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6.Is(are)the well(s);,:.Permanent or Temporary Signal fled Well Contractor Dat
By s,, mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: U Yes or ilirNo with 15A NCAC 02C.0100 or 15A NCAG 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:
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: I(1;' (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 5 00'and 2Q100') construction to the following:
10.Static water level below top of casing: '7'Z) (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 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
13a.Yield(gpm) 5' Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
e- the addresses) above, also submit one copy of this form within 30 days of
• 13b.Disinfection type: granulated chlorine Amount: 0 Ed • 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