GW1--02860_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co actor Information:
add14.WATER ZONES I
Well Contractor ame FROM TO Q DESCRIPTION i
3,,rr1^2� kA'Sft. ,4 10 ft. `C 4iM
tJ ( ``�YY ft. ft. J
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 50 ft. 6 1/8 in' sdr-21 PVC
Company Name
t yJ � 16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: !! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):. ft. ft. 9n.
•Water Supply Well: FROM TO DIAMBI!R' SLOT SIZE THICKNESS MATERIAL
ElAgricultural f Municipal/Public ft ft , in.
0 Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft ft. in.
01 Industrial/Commercial 01 Residential Water Supply(shared) . 18.GROUT •
f Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentanite poured
Monitoring QRecovery ft. ft.
Injection Well: •
ft. ft.
Aquifer Recharge • 0Groundwater Remediation . i
•
19.SAND/GRAVEL PACK(if applicable) •
(Aquifer Storage and Recovery 0Salinity Banner FROM TO MATERIAL EMPLACEMENT METHOD
In Aquifer Test 0Stonnwater Drainage ft. ft. i
Experimental Technology .10 Subsidence Control ft. • ft.
Geothermal(Closed Loop) E3Tracer "20.DRILLING LOG(attach additional sheets if necessary) •' •
FROM ' TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
r_IGeothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
b ft (5 ft red
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4.Date Well(s)Completed:�'f3c Well ID# \, ft. ft. •co5a.WellLocation: a 5 ft �^ it brook.; /w4irk. Yac,lc.
11-cyli , W (1 aMS . ga-ft. ,eft bl iFatyy/OwnerNa Facility ID#(if applicable) ft ft.
St. - ~,rut.* VA IOal�ile, ' tjc.X7Ostf ft. ft. I,.- a.,-. . - V
Phy'�1 Address,City,and Zip o J
4 2 /+y Q� ft ft. , \
kJ�jt .�1 'U C�� 6 21.REMARKS :VIA r 1 a 202
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County Parcel Identification No.(PIN) ' i-`.::,-::_.-•; --.___.Y._ -
it.'C A,,:
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
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(if well field,one lat/long is sufficient) 22.Certification:
on
35. 1 1 N S'S0� W ar --
6.Is(are)the well(s) Permanent or Temporary Sign.:,e.' edified ell Contractor Date
te.fg • is form,I hereby certify'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or }No with 15• 'CAC 01C.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 providedto 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:I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (2-65 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths?I-different(example-�3@200'and 2Q100')' construction to the following: •
10.Static water level below top of casing: - `6 (ft) Division of Water Resources,'Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (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.) I '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center',Raleigh,NC 27699-1636
13a.Yield(gpm) 1 J Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 1./dz/ completion of well construction to the+ounty health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources l . Revised 2-22-2016
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