GW1--07839_Well Construction - GW1_20231205

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-P,ril t Form-`'r l
WELL CONSTRUCTION RECORD (GW-1) for Internal Use Only:
1.W 11 Contractor Information: • 1 ' .
-�©a� 14.WATER ZONES !
Well Contra or Name FROM TO DESCRIPTION
Clio ft. 11 Q D ft. 5n
���A 0s5 ft. Ks ft. (la prINI
NC Well Contractor Certification Number 15:OUTER CASING(for multi [ed wells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM O DIAMETER' THICKNESS MATERIAL
0 ft. ft. 61/8 in• sdr-21 PVC
Company Name
+• 16.INNER C G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: C‘,\,\( \
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.eC,County,State,Variance,etc.) ft. ft. !in.
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3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL
Agricultural,: DMunicipal/Public . ft. ' ft. in. '
Geothermatt(Heating/Cooling Supply) IOResidential Water Supply(single) ft. ft . in. '
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT •
_J 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 0 Groundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • 0Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 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) ® ft. �f is ft. li d
VP5?4.Date Well(s)Completed: 1 1Well UM 20 ft. 3, ft. 1.braontri14,
5 Well ecatip : ,�<y,�+V L,y��!
5. 45 ft. 5 ft. Y 6 e ok
acility/Owner Name FacilityD#(ifapplicable) ft. 535ft. jam_elroevati
I9M � ` l y l 1 14� ft. ft.
ft. `jam] ft.
iysical Address,City,and Zip ^��. : : { j
Plr% •'�to I 21.REMARKS C d.�ri 4;F,,,- D
County Parcel Ide 'ficition No.(PIN) hh nn' C_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DEC C V 5 Z�z3
(if well field,one lat/long is sufficient) 22.Certification: s
5. 69�� 8� �1 I1�.7fYii,E�r1 f fOC�":;?t�' �i/It9�
N a 14 W �l'tf`cfuo� ! 1
6.Is(are)the wells) Eermanent. or Temporary Signatur d We ontractor Date
By sig g this ,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• DYes or )No with 1 A 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 6gok of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 '
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9.Total well depth below land surface: (ft.) 24a. For MI 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: - 50 .(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
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13a.Yield(gpm) ti?... Method of test: air 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 2,,Cj2.- completion of well construction to the county health department of the county -
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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