GW1--03466_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information:
0, *-rti4CA 14.WATER ZONES
Well ContractorNcwR FROM TO D CRIPTION
3��-A 3rt15ft ^1'7� ft. ���
ll ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft ft' 6 118 r_11 _ R$lII-___---- --r�-�
mm� v iName _ 1
__iio.11-siS;n CASuvU oR i unui,.,
2.Well •Construction •Permit#: 05 Y/p 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.
17. N
Water Supply Well: FROMRRF. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricuitural Municipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft in.
DIndustrial/Commercial ElResidential Water Supply(shared) 18.GROUT
fIrr'igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
It. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0 Salinity Barrier -FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test DStormwater Drainage ft. ft
DExperimental Technology Q Subsidence Control ft. ft.
(Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sell/reek type grain size etc.)
o ft 15 ft. real, 4v4
4.Date Well(s)Completed:it (•1 4 Well ID# `5 ft 3 5 ft. brouJh Arum
Sa.Well Location: 35 ft 55 ft. brotet. rock
tS �Y�i) e-s 55 ft. i4koft blue Yay►� " r -4-
Facility/Owner Name Facility ID#(if applicable) ft. ft. %
•
-cn.ci ati.��r_ w�rl� 1�C-�� ft ft. I U N 1 1 L:
Sr"'` ?024
Physical Address, and Zip ft ft.
21.REMARKS frAorA'srwta f.rl 'i^rf 4 i(J.'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Cer. tion:
3 .9 bA5 N .5tk3rl W Si ri/4, _zi.
6.Is(are)the well(s)OPermanent or OTemporary Signet-Li C fled Well Contractor Date
By ling this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or lallo with 15A 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: 4\1") (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:
1.
10.Static water level below top of casing: 5 (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 Infection 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) Lk' Method of test: air 24c.For Water Supply&Infection 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: l(dZ- 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