GW1--06474_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-l' For Internal Use Only: •
• 1.Well Contractor Inform ion:
- �a� . . .' . .. .. .. .. . .. .
:14::WATFRONES: a:t;t �(:s K ::<:;'c•.
Well Con torN,ar�e FROM TO DESCRIPTION~
�^r/ e A ft ft
c'�'1L1J/vn •
ft ft. • i
NC Well Contractor Certification Number •
15.011'.LER::GASING'(fdrmulii aced ivell's)'OR 7‘MIEI2(Mali.liable) `:;:?*: ;s:;':: -
Morgan Well&Pump, INC • PROM TO DIAMETER THICKNESS MATERIAL •
CompabyName > 0 ft Coft •61/8 in. sdr-21 PVC
l Z`i°7l 516:RIMER.CASING:,0161:ukflNO;(gea22iecmalc10:41 loop)* ':::,t.; :;'.':,;, :.:'"::.:
2.Well Construction Permit it: lJ r/.�°, (/ (7� FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft ft. in.
' 3.Well Use(check well use): ft ft. in.
Water Supply Well: :'.17:;;CREEN-. .:•;:•••••:.I:�k R:. ',,.',:::,.:c:::":"c:;.`: • :'::�:"''.:•:.;..,. (::-. ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL•.
"Agricultural El Municipal/Public ft. ft in.
a Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
1 Industrial/Commercial _I Residential Water Supply(shared) •
_I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
a Monitoring EiRecovery ft. ft.
Injection Well: ft. ft.
•Aquifer Recharge rjGroundwater Remediation
:19.SANI)IGRAVEL PACK(if applicable) • .:.: - '• •-
"'Aquifer Storage and Recovery in Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test El Stormwater Drainage ft ft.
I Experimental Technology 0Subsidence Control ft ft.
al]Geothermal(Closed Loop) riTracer .20:.DRILCIII'G•LOG:(attach•additional'sheets'ifn'ecessa y)`:':•••;: :: ::':. ..I„•:'
FROM TO D CRIPTION(color,hardness,soil/rock type,grain size,etc.)
•Geothermal(Heating/Cooling Return) ni Other(explain under#21 Remarks)
4.Date Well(s)Completed: y Well ID# (.it ft / D• ft. t� - n QO C,L
5a.Well Location: S� ft `1 66 �j`'71 Q.�1 1"f j,:.,I....,_. _
iciowrrl Reel ft ft .1 _
2 .` .,. ,.:' R._, " .f• a-_.,j,
•
Facility/Owner Name Facility EN(if applicable) ft ft.
N 0 V v = 2024
q r-'d 0 4/,et/ .
ft ft. .
Physical Address,City,and Zip ft. ft. - t .,,��
ir,`;.; t
'WhU z. .: . . . ,.. : ..... .. ... .
County _ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,00ne latIl ong is sufficient) I 22.Cer• .
6.Is(are)the well(s)JPermanent or DTemporary Siva e of Certified ell Contractor Date
• By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or )No with 15A NCAC 02C.0100 or 15ANCAC 02C 10200 Well Construction Standards and that a
Ifthis 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 thisfonn.
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:l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L (ft) 24a. For All Wells: Submit this form'within 30 days of completion of well •
For multiple wells list all depths ifdifferent(example-3@.200'and 2@l00) construction to the following:
10.Static water level below top of casing: t (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 for*within 30 days of completion of well
12.Well construction Method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) ?...... Method of test: air 24c.For Water Supply&Injection Wells:!In addition to sending the form to
granulated chlorine
�O ° the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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