GW1--06445_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
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1.Well Contractor Information: t
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J.\1 •i' ci 5 t 14.WATER ZONES I. I
`t FROM TO DESCRIPTION I
Well ContractorN/6me ft. ft.
( Cc-CO-l//� ft." ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM TO DIAMETER t I THICKNESS MATERIAL
0 ft. ft. 61/8 in' sdr-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) "
2.Well Construction Permit#: 3•F9 cto FROM TO DIAMETER, . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. C/(r ft. in.
• ft ft in.
3.Well Use(check well use):
17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS . MATERIAL
Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge - DGroundwater Remediation - i
•.19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL;' EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO - DESCRIPTION(color,hardness,sal/rock type,grain size,etc.)
Geothermal(Heating/CoolingRetum)Of �J nOther(explain under#21 Remarks) 0 ft. qz ft f �� di
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4.Date Well(s)Completed: G 1 L/ Well ID# ft ft. i „r}/./...„ 0 o\
5a.Well Location: / ,...)01
l� 'Ca i ;^ ,.}
e.�'2 I Lf C ,�ft 7 (5-ft LI a`;1 .r., a p 1 1 I e
Facility/OwnerNam Facility ID#(if applicable) 1ft. L� ft i
. . 0 COinl)fly. 5-101At CI'/' ft. ft. •ft. ft.
Physical Address,City,and Zip r- ,
,21.REMARICS - j.;• ...v 1^ t_ ', `ii.I 1. -
County 1/`�6 Parcel Identification No.(PIN)
,OCT 0 2
ZUZa 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certification 0r.-:;;s.,-h' Ura
6.Is(are)the well(s)JPermanent or E3Temporary Signature o1/C`e{tified l�Tell Contractdl Date s
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: ,E3 Yes or jNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
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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 theme!'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: Z65 (fL) 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@l00) • construction to the following: , .
10.Static water level below top of casing: / 0 (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) G Method of test: air 24c.For Water Supply&IniectioJ 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: -d, 5 ?Z. completion of well construction to the county health department of the county
where constructed. II
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ( Revised 2-22-2016
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