GW1--04715_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Contractor ormation:
•
lo . ;;,:• .::: _..::;:.:. ' ' . .
We11Con tor Nam• e
FROM TO DESCRIPTION
31/4 k . . t� " t".. ft 3 5P4^
NC Well Contractor Certification Number t�'"b ft ~A ft 5.1P,..)
15:lIT ER.CASING:(foritiulti' ed.welli)'ORLD,vER Oki cable) s L.
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL •
0 ft 4 5 ft '61/8 in• sdr-21 PVC
Company Name
t,• � � ;a!16.'LNNER:CASINGOR.�aBIlVG:(geo'tlie6maldosed-1.00p)`:":.is;: :.'-:�:`..:i.t�<:r'.:?i;.::;i::;: •
2.Well Construction Permit#:tovw,P'" 4 - 5a`d FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft in.
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' 3.Well Use(check well use): ft ft, in. .
Water Supply Well: FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural ElMunicipal/Public ft ft in.
X Geothermal(Heating/Cooling Supply) ffigResidential Water Supply(single) ft ft. in.
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X Industrial/Commercial (Residential Water Supply(shared) .18':GRODT.....`..:: ':-y .' . .
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
•Monitoring EtRecovery ft. ft.
Injection Well:
ft. ft
$Aquifer Recharge QGroundwater Remediation
19:SANDIGRA'VF.>;PACK(if applicable) :. . .
,applicable).:.. ..: ::� ... '�...' ' .. ..' ..
Xi Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 0 Stormwater Drainage ft. ft
Experimental Technology DSubsidence Control ft. ft. •
X Geothermal(Closed Loop) 0 Tracer 20:.11101331NGLOG:(attadraddihonalibeetsIfne'6essary)`;::: ; ;
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
X Geothermal(Heating/Cooling Return) 1J.Other(explain under#21 Remarks) ft ft /)_ I �t•�.�,
4.Date Well(s)Completed:7 f If l+'' Well ID# ft 45 ft �CCt,�_``Q� 1• `
5a.Well Location: 1 45 ft I J ft lY,j1(l—
Jvllite kvCZAtli Ll4 75 ft teas ft Vix_
fz
Facility/Owner Name FacilityID#(ifapplicable) — - :._ .
L ii 3 5) vi 1 t e kd inzresvl I I�c tic 2S I l 5 ft •1.....'‘v` >.
Physical Address,City,and Zip ft ft.
Lifo7
County Parcel Identification No.(PIN) lr:!,:::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) . cation:
22. '
35451( N ?O21Oo w j 7 .)bI,a-4
Si: o i5ed Well ell Co Date
6.Is(are)the well(s)0Permanent or OTemporary I
By signing form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or 17,1 No 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: ff o`K7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
•For multiple wells list all depths ifdifferent(example-3 00'and 2@100' construction to the following:
10.Static water level below top of casing: l) (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 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) U 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: /oi completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016