GW1--03471_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Co actor Info on:
,,vv// odd 14.WATER ZONES
Well Contractor ame FROM TO DESCRIPTION
X15`t. i8o ft q C epet
3C/_,Ce� - ekt ft. ft. .J
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells)OR LINER(if ap llcable)'
Morgan Well&Pump, INC • FROM TO - DIAMETER THICKNESS MATERIAL
0 ft 45 ft 6 i/8- -in. sdr-21 PVC
TrIrly rvamr -,- Q � l0.dfv1v7+,R=GASIL`1t�=0A=ZZiB�G_lgeo[firinaclased-iooP)-- = ---- --- i -
2.Well Construction Permit#: 3Ctn `� 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.
17.S
•
N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural ElMunicipal/Public ft ft. , in.
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) S. g, in.
}i Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
nInigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring ORecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) .
flAquifeI Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft.
Experimental Technology 0 Subsidence Control ft. • ft
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
� FROM ' TO Df,�SCRIPTION(colar hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)
,,�,,`f•--ip Other(explain under#21 Remarks) © f t 3o ft J.�yyr,�h t�l l'
4.Date Well(s)Completed:5/Z/d"� Well ID# �3+b R' 55 ft b�iebt^u. roG�t�••
5a.Well Location: J 5' 365' Q /�.L.►� Q(rcu..tire-
. ` ` '� �� ft ft. t J �,!
Facility/Owner Name X Facility ID#(if applicable) fl ft. t.. •-.i
i7i`�. ;VE[
17�k1 ►rn adc r� �t+�lr �[r �-7°ft ft. j
Physical Address,City,and Zip G' JUN 1 2 U 14
�7�✓ ' 6O14 21.REMARKS Ireforniari-.ta1 P-r.1
County Parcel Identification No.(PIN) D4F;,nQ,ly y�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification:
3S. "ild\tt N s sgstt W "
4-4244
6.Is(are)the well(s)OPermanent or Temporary Si fled ell Contractor Da
is form,I hereby certt&that the well(s)was(were)'constructed in accordance
7.Is this a repair to an existing well: QYes or EigNo I 'CAC 01C.0100 or ISA 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!I-different(example-33 ai l 00'and 2@I00) construction to the following:
10.Static water level below top of casing: v C) (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:
(Le.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) 11 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: lodz 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