GW1--06448_Well Construction - GW1_20231002

P frif:Form:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�\
Well Contractor Namei
UCA) Todd U L 14.WATER ZONES I I
/J ���'!!llII FROM TO DESCRIPTION I
ft. ft.
q55(C.-- 4 ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM TO DIAMETER I I THICKNESS MATERIAL:
0 ft• ft. 6 1/8 Irn' sdr-21 PVC .y
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: N Igsl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. .in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN • '
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
Agricultural fdpctpal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
dustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- bentonite poured
. Monitoring r3Recovery ft. ft.
Injection Well: ft. ft.
• Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft. •
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
_ Geothermal(Heating/Cooling Return)` Other(explain under#21 Remarks) 0 ft* Z® ft 8 roW� „(T r"�
4.Date Well(s)Completed: 1r!4-Z7 Well ID# Et, ft. 2$ ft. Jig/LA
nau-
Z. ft / �C ft. •&- /l
5a.Well Location: ))��• `-�n O -b 7 v_ '•, "(,J
Te'ra"Ct,ievelopfr,e -� ft. ft.
Facilix/OwnAerName
]� �J D' (j� �Facility ID#n(if applicable) (� ft. ft
10 f$ V t J l t W I 5 RJ3de,tt/X/til filer V `i0 1 8 6 ft. ft. j 1;`to a e fin ,.17 t,/?�
Physical Address,City,and Zip ft ft. n
n ��- 21.REMARKS I O C T 0 2.20 23
County Parcel Identification No.(PIN) hs,;;.'.^f'`.:""` 'P''`"' . 1Iri
D,a :`'j,y.•,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certifica' x• ,
35.5675- N gO .3Ir6'7(0 W �-! J~Z3
f
Signature o edified Well Contractor I• Date
6.Is(are)the well(s) Permanent or 0Temporary
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: QYes or tNo with 15A 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#11 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: `�K (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:
10.Static water level below top of casing: /5 (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) L Method of test: air 24c.For Water Supply&Infection 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: 7'J 77 s 5 DZ completion of well construction to i the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016