GW1--00880_Well Construction - GW1_20240205

r
_ ririt;Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •s~
1.Well Contractor Information: j •
rl �:,Y.x�s' 14.WATER ZONES I i
,,, , FROM TO DESCRIPTION '•
Well Contractor ame ..41..r, 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 '
CoropanyNaine 0 ft. ip ft. 61/8 in' sdr-21 PVC
•
I
P`'. r� 4 16.INNER CASING OR TUBING(geothermal dosed-loop)
2:Well Construction Permit#: (�e1 /S1 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural QMunicipal/Public • ft. ft. in.
0 Geothermal(Heating/Cooling Supply) Ai Residential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial OResidential Water Supply(shared) 18.GROUT. • ' •
I--'4Irrigation 5 i FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: "' 0 ft- 20 ft• bentonite poured
Monitoring ORecovery ft. ft. .
Injection Well:
ft. ft.
0Aquifer Recharge r 3 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
QIAquifer Storage and Recovery Salinity Banier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test [3 Stormwater Drainage • ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
0Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheds if necessary)
0 Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks) FRoM TO DESCRIPTION(catoq hardness,soWrock type,grain size,etc.)
0 ft. 20 ft. d_e / ,.J
4.Date Well(s)Completed: / Z �� Well ID# 3 0 ft. L.)G ft. 13 f oti i ` ss J•-1-
5a.Well Location: 7 4 (� ft. •7 0 ft. %6L.‘„)„V<4co 4 y �cDcif/ /1d .e//Ll/r� 60. 70/ ft. 1 ftI Lit, r rill '+t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. 8 *,.. EL......Y' v; "'i:.y
01 21.REMARKS .L"[p 0 5 2021
County Parcel Identification No.(PIN)
imorm-. -n Ps•c-. K
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
:F 3 Ui(if well field,one lat/long is sufficient) 22.Certif ation LTti'< Y �w
3S5IfUGV N J dg1Z 1 W 1. � %c� r . ! -IL Z3 •
6.Is(are)the well(s)JPermanent or Temporary Signature of Certified 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 jNo with 15,1 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thal 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 Me well owner. -
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well detail's: .
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-I 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: '7 t7G _(ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-'3taJ200'and 2(a3100) construction to the following:
10.Static water level below top of casing: ct) (ft.) Division of Water Resources,Information Processing Unit, •
If waterlevel 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 SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 7
13a.Yield(gpm) Method of test: air 24c.For Water Supply&Infection I 'Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
type:. Amount:granulated chlorine
13b.Disinfection • 3 01 completion of.well construction tol tiie county health department of the county
' where constructed.
•Form GWpl • North Carolina Department of Environmental Quality-Division of Water Resources :: Revised'2-22-2016-