GW1--04850_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
FROM TO DESCRIPTION,
Well C tra tor Name
ft. ft H
. ft ft
NC Well Contractor Certification Number t
,15i;0UTER:CASING{for'miilti:ravedweIl`s)ORL;<NERC���P licable) 7;
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft it 6 1/8 �' sdr2l pvc
Company Name, ,•..�;,--.
16 E 10.--C94G
'ORrTIIBING(geot eermal close"dloop) ;'��,
2.Well Construction Permit#: 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: F SCREEN ptl a DIAMETER SLOT SIZE THICKNESS MATERIAL
.II Agricultural 0Municipal/Public ft ft. in. •
U Geothermal(Heating/Cooling Supply) ?' iResidential Water Supply(single) ft ft. in.
• •1 Industrial/Commercial OResidential Water Supply(shared) ` -- -. . _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non-Water Supply Well: 0 ft 20 ft bentonite poured
RI Monitoring ID Recovery ft. ft.
Injection Well:
•
ft ft.
_Aquifer Recharge _I Groundwater Remediation
19r:SAND/GRAVELPAC&(rf`ipplicable);:a. = =:'=as
.-]Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ell Stormwater Drainage ft ft.
Li Experimental Technology DSubsidence Control ft. ft.
-:Geothermal(Closed Loop) ;Tracer Yi20 DRIhSIl!TGZO'G:(aftacliadditional`sheetsi$neceasary) i
`�i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks), -2-'-_-'-.--
''.;.--FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,eta)
•
lIlft 1m ft. bwr. ak4.Date Well(s)Completed:1 1�..S Well ID# to ft .•a�J, ft of ry +,5a.Well Location: Sc ft DOS e .3 AF-TC.-•
C -N ILNCA' u A ft. ft
jFacility/Owner Name�X Facility ID#(if applicable) ft f ft w.C.—,r,,a...,e; ;�"
1 lJllr i,E �-k�14`, 'r ft. ft `- �^-�s✓L.,: t Li
ac
x�\ Yl..+) ft ft.
Physical Address,City,and Zip I
��h7h���e '21'I2EMARTCS' ., . e-
._ ..... - _. :::r; t-:`_4 0,3. 3.
County . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,one let/long is sufficient) 22.C • cation:
`) eljJ —c N )" 's- W (C
6.Is(are)the well(s)�Permanent or Temporary
Signaffied Well Contactor a
By s= ing th .nn,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D_i Yes or IffiNo 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: (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 00'and 2@100') construction to the following: •
10.Static water level below top of casing: (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 (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:
(ie.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
air pressure 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
13a.Yield(gpm) Method of test:
'f!: / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: SQ:i' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Caiol ea Department of Environmental Quality-Division of Water Resources Revised 2-22-2016