GW1--01385_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
3t Tbdd -&1%,
1.4.WATER`ZONES, ,: l`!i
-
Well ContractorName
FROM _ TO DESCRIPTION
( [' r ft. ft. I '
/ Vc ID -A ft. ft.
NC Well Contractor Certification Number -;15.:OUTER'CASING!(for inuln cased wells)OR LINER(if ap`licable) '
Morgan Well & Pump, INC^'V C FROM TO DIAMETER! THICKNESS MATERIAL
Company Name 0 ft• fig ft. 61/8 , in• Sdr-21 PVC
�I 16.INNER C G'OR TUBING:(geothermal closed-loop). 't,.
^2.Well Construction Permit#: 0 t/b 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
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) NOResidential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)` `• _ '' .'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
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❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG(attach addtiionalsiieets'if necessary) � ' _
FROM TO DESCRIPTION color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling9 Return)) ❑Other(explain under#21 Remarks) 0 ft. 14 5 ft. 0 ec j)
4.Date Well(s)Completed: ` _"4 Well ID# C. 5 ft. Cb ft. /3pj ./^ d / ri
(f 0 ft. /z� ft. p / tSa.Well Location: 1�1 `/�U/rrl� 77M/P4o4 f Da ft. 1 l5 ft. n
Facility/Owner Name Facility ID#(if applicable) ;` 1 S ft -ZAS ft in. �r�co ';�e'
lair 41 ft. ft. 1.
Physical Ad ess,City,and Zip ft. ft.
L,c a 4 -31.REMARKS . _ -- -ate
County Parcel Identification No.(PIN) M..— t V I.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M AK 0 4 �OZ�
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(if well field,one lat/long is su� N ! Jl 1 z / W ient) 22.Certif a'ow
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Informe iTn 7rnt--Ct^v 1, Z.
6.Is(are)the well(s): MPermanent or ❑Temporary Signa. eiv.rtrfie ell ontrac r ate
By signing this form,I hereby cent fy that.the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarin 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: tg6 (ft.)
For multiple wells list all depths if different(example-3 r)200'an 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form:to Division of Water Resources (DWR),
� (ft.10.Static water level below top of casing: c ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and OpenLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1(/
�j Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
f
granulated chlorine -L ` Q 7
13b.Disinfection type: Amount: D V
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018