GW1--03829_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
FROM TO DESCRIPTION
Well Contractor Na a ft ft
ft ft
NC Well Contractor Certification Number " '- -, '-
15:OUTER CASING*—Fiiii lti rased aeells ORIArTER i 'a hcable Y ,`
Morgan Well & Pump, INC FROM O DIAMETER THICKNESS MATERIAL
1 ft ft 6118 m' sd21 pvc
Company Name
�� 16 IlDDM C-AS .G-Or—MMG 'eoiliermal'rlosedlo'o ? z
2.Well Construction Permit#: n C� FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e. C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in
Water Supply 17. SCREEN
PP Y Well: FROM I TO " - DIAMETER SLOT SIZE� I THICIUMS MATERIAL
LJ Agricultural [3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft I in
f Industrial/Commercial DResidential Water Supply(shared) ��g;.GROUT'. s =`=
Ell Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
Non-Water
F3Recovery ft ft
Injection Well: ft ft.
Aquifer Recharge DGroundwater Remediation
419�SAND/GRA3!ED$ACg rii"lrca'$le >:_>,ar?�.'.r .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
_i Aquifer Test Stormwater Drainage: ft. ft
I Experimental Technology J Subsidence Control M ft.
-i Geothermal(Closed Loop) [ITracer 20 DRIIMUINGT,O.G-,itttacli:ad3itii rial`sheets:dt'neceas8 G.FROM TO DESCRIPTION color,hardness soillrock e, size,etc.)r
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) it lo ft G
4.Date Well(s)Completed:�� Well ID# ft SS ft fow/� `
ft ft
5a.Well Location: '
/��K �Q ^���/ ft M
� G � it ft
Facility/Owner Name Facility ID#*(if applicable)
i l W ft ft
Physical
/a Add es/Cii;y,and Zip ft ft
// (�T1.(/I/ 1 .21eREMr'172YfS.'�;; r,.y.- •�:. ..� � `` -,. r4,
County Parcel Identification No.(PIN) r Ar LJrsl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
0 N
6.Is(are)the well(s)�J Ix Permanent or OTemporary SiguatWoMAfiedVfell Cd6ntaabr 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: ' Yes or 'xl 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 ofthe copy ofthis 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: C (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3V 00rand 2@1000 construction to the following:
10.Static water level below top of casing: C7 (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 (in.) 24b.For Iniection 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) Method of test- air pressure 24c.For Water Supply&Iniection'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 chlo ine 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