GW1--06449_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ' •
1.Well Contractort— Information:on i
CAon\ (f J an. 14.WATER ZONES i
ww FROM TO DESCRIPTION I
Well Contractor Name L[]^(eft. f n 1 H.
���' , 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" THICKNESS MATERIAL
Company Name ^
a ft. 35 ft. 61/8 in' sdr-21 PVC
(�+It S� 16.INNER CASING OR TUBING(geothermal closed-loop)
3
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.
17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ED Agricultural °Municipal/Public ft. ft. in. I
0 Geothermal(Heating/Cooling Supply) E'I sidential Water Supply(single) ft. ft. in.
°Industrial/Commercial °_.'Residential Water Supply(shared) 18.GROUT
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft- PO ft. bentonite poured
°Monitoring i °Recovery ft. ft. ,
Injection Well: ft. ft.
DAquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
(Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
0Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) .0.I1 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) O ft. a O ft. ( r y I- C
CtAj
4.Date Well(s)Completed: Cl IS?I �� Well ID# a 1, ft. 5'51 ft. r-at, 5}?,t(/)v
5a.Well Location: .titj ft. ft. (�
J aw l 01 r\ ft. ft.
Facility/Owner Name
Facility ID#(ifapplicaable)) ft. ft. ; r—, ;--.r--_ f,-:,*1 ',,r,, ^.1.J t.� �i � 7,a ;,1q \ QunnsS11 a ac4 _ liile /j ft. ft Physical nAddress,,City,and Zip I (� ft. ft. 0 r T 9 2073
tANV WU t tO li r I OU 21.REMARKS 1 I 0
County Parcel Identification No.(PIN) i R'J`t'`�
..II P ..l II l:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Sr Q 1 22•Ce tification: o�
2 S1 7 N O 0 t �a-I(Ji3 W • . •
J6.Is(are)the wells)JPermanent or TemporarySiggnature of Certified Well t_11
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 jNo with 15A NCAC 02C.0100 or 1SA 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 421 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: 5 DO (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:
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
11.Borehole diameter: 6 /8 (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: 1
(i.e.auger,rotary,cable,direct push,etc.) h I
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 I
24c.For Water Supply&Injection 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: 2 2 completion of well construction to ie county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I ' Revised 2-22-2016
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