GW1--03358_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
a\�r� 14.R WATER ZONES
Well Contract Name FROM TO DESCRIPTION
ft ft
c�►S (p----P' 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
otuaa Nam:. - ft ft t In. PVC -J.
6j r
2.Well Construction Permit#: MCI-a
List all applicable well construction permits(Le.U1 ,Co unty,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. 3n.
17. N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural OMunicipalPublic ft ft. in.
QGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite poured
IDMonitoring 0 Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge IDGroundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
(Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology EtSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) /U - ft 10 ft. 6 ��^� ry,
4.Date Well(s)Completed:41-lit-..t L1 Well ID# 1t0 ft ' (1 ft. 0%4 A, n C�ak
5a.Well Location: 'L$ ft. 14[ ft. 'JIC, ' .- 1f,
iciopCor ft. Jft \ ..
Facility/Owner ame n n e Facility ID#(if applicable) ft ft. F.L:V C: yi
7 �V�l J �11�V 5 W u� ft. ft
ft ft JUN 1 0 t3 4
Physical Address,City,and Zip
(ail CO J 21.REMARKS WINIMge it r..f.*A aw'ibi Ulla
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 1 22.Certific
SS •it)"J b N 0 I O/ S�3 W
6.Is(are)the well(s)jPermanent or OTemporary Signature of rt red Well Con ctor 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 EgNo with ISA 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 1 GW-1 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: 1 , (f) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 e@200'and 2@100) construction to the following:
10.Static water level below top of casing: C.'10 (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 Iniection 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Z Method of test: air 24c.For Water Supply&Iniection 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: / O) completion of well construction to 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 '