GW1--05775_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: l • 1 I
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� � O• .14s:WATER'ZONES :: ..`?:_-_1-slaL K__ . .,.: , .......�:C_• ..,_ ..
Well Contractor Name FROM TO• .DESCRIPTION
tiCcd- ft. ft
ft ft I
NC Well Contractor Certification Number
XIVOUTEFLCASING'(for`:multi=esbidlirells):ORIJNER'(ifap livable)-: >°;r': .:_-,
Morgan Well&Pump, INC FROM TO DIAMETER : THICKNESS MATERIAL
1 ft 76 ft 61/8 I '• sd2 p
1 vc
Company Name `,
�� �� �� (16iINNERCASING.OA,TUBING(geotheimal"closed=loop)ir��=r :,-�"; �..,...
2.Well Construction Permit#: s 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): it ft. in.
:'17:SCREEN.�.r?`.': .: •. � , r :? _ :: .,,.,;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural CIMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) i ;.
'Irrigation FROM TO MATERIAL` _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
• Monitoring E3Recovery ft ft. '
Injection Well: '
ft. ft.
Aquifer Recharge Groundwater Remediation S.SAND/GRAVED;PACK(if appliciitile) p,..-
'? .
Aquifer Storage and Recoveoy 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0StormwaterDrainage ft. ft
Experimental Technology Subsidence Control it. ft
Geothermal(Closed Loop) ®(Tracer ',:0:`DRIL 1NGLOG'6itficli additiouarilfOtsi€rieceasary)rr` - _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)`
I Geothermal(Heating/Cooling Return)se 7�22Other(explain under#21 Remarks) ^
1��(� 0 ft go ft n�� i'd11i
4.Date Well(s)Completed: Well ID# go ft S� ft 13 ro w(\ d t- �`'}
5a.Well Location: 55 ft "� 1 ft rc '-r' D�,iJ
Qo d. a/ U.;A 7 I ft. -�/15s ft t U ran ,- t ei
Facility/0' erName Facility ID#(if applicable) ft. it (�
95 C;�d� Ln it ft :"' ., _i /E p I
Physical Addresss,,(Dr
,and Zip ft ft. [j} -2 (l t
„-ibe.l (A5 fZ1:RF.7IRARKSjti�,,i�f,s_:. ..v� r',....,:..c. ,,....: Gf.,e;V 5.:- .4r,2J-„,..i
County( Parcel Identification No.(PIN) lf}l`virr,aZa4:ri Ptr..,:toue.9 Un.ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tawc,AKIG
(if well field,one lat/long is sufficient) 22.Cerlifica•,i
_c-i7 ,g
N ccas 53(i)/ %, �
F-//-45 .
6.Is(are)the well(s)Jx Permanent or Temporary Signature e.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: DYes or EIINo with 15A NCAC 02C.0100 or ISANCAC,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:' i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / C (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 00'and 2@100') construction to the following: i'
10.Static water level below top of casing: '6 O (ft.) . Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centr,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) so 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 Amount: (Q•5 7Z, 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 j . Revised 2-22-2016