GW1--07848_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
7 "helot "3-
14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
Y��G( _A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well&Pump, INC FROM TO , DIAMETER THICKNESS MATERIAL
a ft. S ft. 61/8 in. sdr-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �/ ft. " ft. in.
List all applicable well construction permits(i.e. I ,County,State,Variance,etc.)
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ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
I Agricultural )Municipal/Public ft. ft. in.
li Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Mi Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 20 ft. bentonite poured
II Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
II Aquifer Recharge !__l Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
]tAquiferTestStormwaterDrainage ft. ft.
*Experimental Technology 0 Subsidence Control ft. ft.
MI Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,s it/rack pe,grain size,etc.) •
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) Oft �7 ft. fo )_f�
�- 77 (�/V ft. wV' t �`�
4.Date Well(s)Completed: / C).- 23Well ID# ! Z (-/l/)V' 1(
5a.Well Location: ?ft.
ft. /6 C ft. /Vf e, �(�' rlh)'--S
pb01 6-71A"!_✓��V1jt�A ft. ft. l REU.;EIVED
Facility/Owner Name Facili ID#(if applicable) ft. ft.
/ Vb PO)i CO'- Orel Li
ft. ft. , DEC 0 5 2023
ft. ft.
Physical Address,City,and Zip
/� z1.REMARlcs In4cra :«a ?t:c a:na Ln
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s)jPermanent or DTemporary Signature of Certi ell 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: jYes or jNo with 15A NCAC 02C.0100 or 1.54 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 fonn. 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:' 77��f�j, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .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@20 and 2@l00') construction to the following: -
10.Static water level below top of casing: 2 (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 1/8 (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) •10 Method of test: air 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: / " �®� 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 I Revised 2-22-2016
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