GW1--04799_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1. Contractor formation:
Ill_ I O 14 WATER ZONTES .
FROM TO DESCRIPTION
Well Con for Name
3)a _ k 1445 ft 141 ft.
O
'6S ft. E`th ft. 7w 11�I�oi
NC Well Contractor Certification Number C15;:OIPf;ER,CASING:(forJ ii1ttAsed.wells)ORLINER(if.ap'lirahia)a•?., :.;:;':.
Morgan Well & Pump, INC • FROM TO DIAMETER— THICKNESS MATERIAL
0 ft. Ili
ft- '61/8 in. sdr-21 PVC
Company Name
�� 16.'INNER:CA;SING-OR 1.1BINGIgeotlieimalelesed-loop):: ,,c.....;
2.Well Construction Permit#: FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perm (i.e.UIC,County,State,Variance,etc.) ft ft in.
• 3.Well Use(check well use): ft ft in.
Water Supply Well: •::I7SCRSEN::;.:::: ::':: :F;•j.jC:..'>:.. ' '::"":':,;.,c.'.':: . .;-`_.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft, ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
__ Industrial/Commercial 1 • �J Residential Water Supply(shared)
IS;GROUT
t_- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft- bentonite poured
Monitoring [Recovery ft. ft
Injection Well: ft. ft.
-
inj
Aquifer Recharge f Groundwater Remediation
19.SAND/GRAVEL PACK(if applicahls) . :'
D Aquifer Storage and Recovery fSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fi Stormwater Drainage ft ft
Experimental Technology []Subsidence Control ft ft •
Geothermal(Closed Loop) EDTracer 20:I)RILLINGLOG: attacfradditional'sheetsifneccssa' .
1 Geothermal(Heating/Cooling Return) !-=f Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
nd oft20fteetid-.
• 4.Date Well(s)Completed: l I_I• I Well ID# ft s ft.
55aa.,,Well Location: /t /(e4 5 ft. 6 ft tYCLA*
�/ N1( /_rrs xt /� _id'" It) ft Ifs ft. v�.e __h a
Facility/Owner Name �/ (� Facility ID#(if applicable) ft ft
/13 rtbit..., h Mo�ec'f , Alt, 73•/12- 4.--
Physical Address,City,and Zip /A' �yf/, /� ft. ft. d t� (� d
6 J!I ✓ 0`t♦7 '2S ltF'iagles�... e�: j!:. t,t. �r, lK,�3ai,
l�n�o� q
County Parcel Identification No.(PIN) _-. _ • ' •°,-,* -.•j,:t
C'f: _-.3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 2 i(cation: -
34, 962oa N �(:). 49a-5 W !6 _
6.Is(are)the well(s)JPermanent or nTemporary Sign/a oartified Well Contractor • D e
By signing form,I hereby certifiz that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: U Yes or No with ISA NCAC 02C.0100 or 15A NC/IC 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: If
5 (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@200'and 2@a l00') construction to the following:
10.Static water level below top of casing: 4b (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) 3 Q 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: 71L 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