GW1--06446_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
'0.-t` d J�
14.WATER ZONES I
FROM TO DESCRIPTION
Wellontractor Nadeft. ft.
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 �'gg DIAMETER! I THICKNESS MATERIAL
0 ft. '� [ ft 6118 I in! sdr-21 PVC
Company Name •--�3 2 16.INNER CASING LLOR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 357 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. I in.i•
ft ft. in.
3.Well Use(check well use):
17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) +(Residential Water Supply(single) ft. ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation
Non-Water Supply Well:. 0 ft. 20 ft. bentonite ! poured
Monitoring E3Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft.
Experimental Technology Et Subsidence Control ft. ft
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ._ Other(explain under#21 Remarks) Q ft S%'s ft. ,e.) '/9
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4.Date Well(s)Completed: l `?Well ID# �(5 ft `� ft /2/ �.n it
5a.Well Location: 103 ft ZZ ft. G,7 f��/ .c
(' l `' GGUI,.W ft. ft.
Facility ID#(if applicable) ft ft.
Facility/Owner Name .'-.
lJ 1j,�t poirci ft. ft. ,--•,;"("-" -A,i• k.,y iA,
, N ` "1 '`
ft. ft.
Physical Address,City,and Zip
ko r wVv'etn 21.REMARKS 0 f l Q ') 7023
County Parcel Identification No.(PIN) ':_ i ir''
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: iP G�k. .:,f•.`w7
(if well field,one lat/long is sufficient)cici l 22.Certification: G� 7
CJ � C1� N L/b��� W ` _/&-Vy
6.Is(are)the well(s)JPermanent or EllTemporary
Signature of Certifte Well Contra Date
By signing this form,I hereby certij5fr that the ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ElNo with ISA NCAC 02C.0100 or ISA 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: 15 (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: 1
I
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
I.
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 tliislform within 30 days of completion of well
12.Well construction method: construction to the following: pl
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,iUtiderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: air 24c.For Water Supply&Iniectio I Wells: In addition to sending the form to .
ci the address(es) above, also submit l one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: Z' completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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