GW1--07846_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
„Itntractor Information: i
_�rf I
(7/1 14.WATER ZONES f
Well Contra r me �WWCs FROM TO &so
PITION
ft. t���7 ft.
' z A_ �[� A ft. fL 0 ,
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
0 ft. ft. 6 1/8 in. sdr-21 PVC
Company Name 2.Well Construction Permit#:- eirtb 16.INNER C DIG OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.Ulou„ty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
7.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural fMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) vigResidentiai Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Inlgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring El Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Banier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
_ FROM TO DESCRIPTION(cola,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) b ft. is ft. ff
4.Date Well(s)Completed: , IVell ID# ,� ft. �J ft. � y �l� �i
5a.Well Location: 5 ft. 1 d ft. . ir'- (((Y.
7 �'rR C �6 ft O i�� ft. � 1�'�' )��
LA �.J��`' (ifapplicable) tb ft t6b ft. T hJ�k rtJ✓Facility/ wnerName FacilityID# a licable '
5 \66 ft. 5 ft. 43r., yrt.vi
P sical Address,City,and Zip 2 ' > ft. ft.
21.REMARKS
�A(`► �? Rr-C.:F� ---
County Parcel Identification No.(PIN) — 0 t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DEC 5 2023
(if well field,one lat/long is sufficient)
f'� 22:P fication: l•
r C\ N - ll01G9P7 ,
W ln(Qr-nv,Iicn 'r ctxaus. .- l tq.
D
6.Is(are)the wells) Permanent or Temporary sign,. of ertified Well Contractor DateBy s'nin:ffl form,I hereby certlfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (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 00'and 2(g100') construction to the following:
10.Static water level below top of casing: b (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 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: I
(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) 5 Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submitI one copy of this form within 30 days of
granulated chlorine completion of well construction to the county health department of the county
13b.Disinfection type: Amount: (3�
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016