GW1--03368_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-k) For Internal Use Only:
1.Well Contractor Information:
4-- 14.WATER ZONES
(� \ FROM TO DESCRIPTION
Wellrontracto►Name ft. ft.
v (—A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ilcable)
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft, 8 i/$„,-: in' sdr21 _ PVC.>- -
x
_"-- — • + __ _ _ -- - n . 1 RN TN:loco __-- - _ ___-- -
_ - -__.____ ___ „rr--��t__rpR'tt1}}�_C�� ,therrnatdosed-loonl_ _ i _
-FRONT--TO -DIAMETER-- IIICi{iIESS-- iviATERui - -
2.Well Construction Permit#: in.
List all applicable well construction permits(i.e.UIC,County, ate,Variance,etc.) ft. ft
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural ['Municipal/Public ft ft. in.
0Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
0Industrial/Commercial esidential Water Supply(shared) 18.GROUT
fl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft (llL ft b`entonite rolPtd
rj Monitoring ['Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge d Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
13Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test 0 Stormwater Drainage ft. ft.
©Experimental Technology Subsidence Control ft. ft.
ElGeothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o ft 1 ft /�/,�i♦(V11 r.J}
4.Date Well(s)Completed: S:3 2ti �j
Well ID# oft' I 0 ft' ib(o"I rfir
5a. 1 ft. `1D ft. '(own
itgqk
o,,WellLocation:n ( /' i � 1
Facility/ N Facility/Owner e Facility ID#(if applicable) ft ft ft. tietc ft. U
� ee1 Di' ft ft t.. ---:
`-' r" Jig
Physical Address,City,and Zip ft. ft 11'""`/`�
If\b1 N 21.REII7ARKS IUN , 0 1424
County Parcel Identification No.(PIN) °WI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . 1_p�`f �
(if well field,one hit/long is sufficient) 22.Certifica'on: �"
•
35_531 I N 1/. 12y2tj W S r(,3"2t
6.Is(are)the well(s)JPermanent or E3Temporary Signature of Ce fled Wel n 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: ['Yes or RrilNo with 1SA 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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:
(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) ZJe/ 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: [1_ 9 Z. 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