GW1--04897_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
. 1.We Contractor Information:
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14:,FVATERZUNES ., <,.. s__�ab.:• _:,._ .
FROM TO DESCRIPTION
Well C Ira torName
42z—A.
ft ft
NC Well Contractor Certification Number �-
;15`;OUTER:CASING:(formultivcased.Wells),OR=ONEitkif:ap liczb'le) `' Z
Morgan Well &Pump, INC FROM j04 DIAMETER THICKNESS MATERIAL
1 ft. .)_ft. 61/8m• sdr21 pvc
Company Name , �] 9 r:16'.IN1 E. SIN LGG OR=TUBING(e`o'thermal closed;loop) ',�
2.Well Construction Permit#: `�' q, rig 6 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. •
Water Supply Well: ±- SEREEN;M p',`=: DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural )Municipal/Public
- ft. ft iin.Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft �, in.
'• IIndustdal/Commercial Residential Water Supply(shared) _ - _ -- _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20-- ft bentonite poured
Monitoring DRecovery ft ft.
Injection Well:
ft. ft.
II Aquifer Recharge En Groundwater Remediation
,'19:.SAND/GRAVEL`PACK(if:apphcable) ;n,,f"7-.al`_ ;`'::
r*IAquifeI Storage and Recovery 0Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD •
*Aquifer Test DStormwater Drainage ft ft
R Experimental Technology IDSubsidence Control • ft. ft. •
$GGeothermal(Closed Loop) DTracer =`20:DRILL TGIOG"(attsch'addition"a1"s$eetsifpe"cea"sary)' -t: r_:
*Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type ar un s ze etc.)
�] i d ft /5- ft. reed tl_
4.Date Well(s)Completed: 6 !`-\ Well D# E 6 ft ft. (! U,��r3► `
5a.Well Location: •
111 4I4?)
it
J_b ft. rai.,f j1,1.
\( ^'6-kkc\ 66 ft. p7 ' ft. `
FaacCcility/Owner verl '�Naame Facility ID#(if applicable) '7 ' ft ft u) y YL k
1A Pa-6, 01(001114 VSIFu it 146 t.M. 0-06. biue. Orgr,r ,
Physical Address,City,and Zip ft. ft.
dD5 r : ..RF.MARK.S.-- _::• _ _ • u A .y_µ;
County . Parcel Identification No.(PIN) I I a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J I.)t 2 t7 2073
(if well field,one lat/long is sufficient) 22.C• .. cation:
. .2._ � 1V'1i-r4R1:•SI fit',^;:9.44:r„g l:liil
Si 'f ill—'sect Well Contractor Dat t
6.Is(are)the well(s)*IIPermanent or Temporary
By s o ng th+ •rm,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or *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:
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: (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: .� (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 Infection 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 Sea-vice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3O Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
Xr� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: t)b2, completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016