GW1--02854_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co actor Inform tion: I
Inform
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14.WATER ZONES I !
Well Contractor ame E�/ ft deg
ft.ROM ToDESCRIPTION
3 ,/ t p�kD7 ft ft. �r�I l 1
NC Well r►�Contractor(CertificationNumber 15.OUTER CASING(for multi-cased wells)IORLINER(if ap licable)'
Morgan Well&Pump, INC FROM TO - DIAMETER ! , THICKNESS MATERIAL
0 ft. ft 6118 rn. sdr-21 PVC
Company Name
1 16.INNERCASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:3 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Le. IC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):' ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMBIB,R' SLOT SIZE ' THICKNESS MATERIAL
0Agricultural EtMunicipal/Public ft. ft. , in.
0 Geothermal(Heating/Cooling Supply) ;'Residential Water Supply(single) ft ft. in.
fI Industrial/Commercial OResidential Water Supply(shared) .18.GROUT
f inigation FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring 0Recovery ft. ft.
Injection Well: .
ft. ft. •
Aquifer Recharge • 0 Groundwater Remediation •
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage ft. ft.
Experimental Technology '10 Subsidence Control ft • ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG(attach additional sheets if necessary) "
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTI,] N(color,hardness,soil/rock type,grain size,etc.)
d ft 1� ft reei 04
4.Date Well(s)Completed /. 3/.1M Well ID# ft. ft.5a.Well Location: 5 ft 46 ft. K VocL •
MA) ,'Irif • Cy ft. �V� ft 1`-
Facility/Owner Name Facility ID#(if applicable) ft ft. Y I--`• x E, :. ,.•t i: ; ,, ....-
1.
616 Ca p �! l( L. 1, Nc 2$/ ft ft. MAY 1. A 2024
Ph si Ucal Address,City,and Zip ��{ A ft ft
p( 1 T. -Oas 21.REMARKS • • • { - - i `, -r L.'.•;�."yr .i r:.
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) 22.Certification: •
;35.643<1 N/5.(02.6b wgig/cA
6.Is(are)the well(s) Permanent or Temporary Si e.' citified ell Contractor Dat
• is form,I hereby certify}hat the wells)was(were)-constructed in accordance
7.Is this a repair to an existing well: QYes or FA No with IS CAC 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 GeoprobetDPT 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:' a j�"� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')' construction to the following:
10.Static water level below top of casing: 60 (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: '
(ie.auger,mtary,cable,direct push,etc.) 11 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) P - 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: 12.�. completion of well construction to the County health department of the county
where constricted. ' '
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I. • Revised 2-22-2016
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