GW1--00864_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informati n: `�
v61, d C �Y. 14.WATER ZONES I
Well Contractor Name TTT FROM TO DESCRIPTION
��5��-� ft. ft.
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
0 ft. deN 2. ft. 61/8 j in. sdr-21 PVC
Company Name
/S 16.INNER C G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: G/11 ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: FR MCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring ORecovery ft. ft.
Injection Well:
0 ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Batrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft ft.
Experimental Technology rjSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) t 60 ft. D ft. B/UW" art.
4.Date Well(s)Completed: r 2r���,ZVellJD# a ft. go ft. S,1614
[yF /
5a.Well Location: 6 ft. /ej ft.
1/ 2e t Gett at o ft. 67 ft. J..,n /�9ck:
Facility/Owner Name Facility ID#(if applicable) 87 ft. 9pv ft. 6 Ci++1.(,/`�f,
/V 7/2'�V (? ,4 l t.lr 1 fze (J ft. �/ ft. V
Physical Address,City,and Z i ft. ft.
641014 21.REMARKS (_',- I—, . .
County Parcel Identification No.(PIN) /;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F C D 0 5 2024
24
(if well field,one 1at/long is sufficient) 22.Certifi �/ !'
. 5Y�� N Al t 4��1 1>,,crr,.,�1`1tl7r: (. ,: �V{�1
W r� D��� 3O GZ a(*y
6.Is(are)the well(s)JPermanent or )Temporary Signature of ertified Weil 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 EINo with 1SA 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. -
drilled:' /f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (P 014 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: So (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 Ce[nter,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test:.air 24c.For Water Supply&Injection,Wells: In addition to sending the form to
7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine 5 Amount: 6, 0( . completion of well construction t i 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