GW1--05354_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
. 1.W ctor Information:
`Ct 14 WATER'ZONES'
Well Contractor Name FROM TO , DESCRIPTION
*'�—° 'Sops ft. 3n,� ft. 20 14.eV"
ft f4
NC Well Contractor Certification Number • Z15.,OUTER:CASING:(for multi-cased.wells)OR LINER(if aP livable):.
Morgan Well &Pump, INC • FROM TO DIAMETER THICKNESS MATERIAL
0 tt. go ft' 61/8 in* sdr-21 PVC
Company Name
_J_�, w 16.INNERiCASINGOR TQBING.(getithermal clawed-loop)..;: ..::
Ck 2.Well Construction Permit#: 'y— •�e� 2oA—�\, 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
Water Supply Well: 17_SCREEN.. -:: Tr:,.•:>..
FROM TO }DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural DMunicipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) gliResidential Water Supply(single) ft. ft. in.
['Industrial/Commercial 111 Residential Water Supply(shared)
p� IS;'GROUT .::
fl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft• bentonite poured
Monitoring ['Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ['Groundwater Remediation
.19.SAND/GRAVEL PACK(If applicable) ...
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test ['`'DStormwater Drainage ft. ft.
['Experimental Technology .['.r Subsidence Control ft. ft.
['Geothermal(Closed Loop) [Tracer 20:DRILLINGLOG(attach adtiitloniiisfieetsafaecisisaryy"i."•' :;:: ".. :. :. .: :.>:
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM To DESCRIPTIO (color,{A-ar-
Qdnesa son/rock type,grain size,etc.)
40 ft. "� ft r %r
4.Date Well(s)Completed: (� 1 U*-Z1Well ID# 'LQ ft. As " t WE)1.0N c 1 f.•.
5a.Well Location: 4 5 ft. 1 O ft. broulfri r c —
via, ekaa\-t- rlo ft- 32,b ft- truj poz.r.bc,
F�accilityy//OwwnnerName I, (� Facility
-lD#(if applicable) �`^ ft. ft. r" ,:7l+, _. L/
Physical Address,City,and Zip
ft. ft SEP 0 9 2074
LOOCLDVS Iri(o Ti.t.f•ri il ,. „t Urt3:
County Parcel Identification No.(PIN) D'hCetztiG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ' cation:
3S , 45Z.$) N 120. 69 k 1 W
--4-3-72-41
6.Is(are)the well(s)ElPermanent or ['Temporary Si o tified Well Contractor e
By signing ftl�fsform,I hereby verify that the well(s)was(wet•e)constructed in accordance
7.Is this a repair to an existing well: ['Yes or )No with ISA 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.
`filled'' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 -1::::0 (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@100') construction to the following:
10.Static water level below top of casing: U S (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) 4P•4-6 Method of test: air 24c.For Water Sunnly&Infection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 1�G� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016