GW1--07854_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
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1.Well Contractor Information: I
TDdel 1 .
�` 14.WATER ZONES I
Well Contractor)(lame FROM TO DESCRIPTION'
C `/� ft. ft. '
CbSG _!LF ft. ft.
NC Wel 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. eib
ft. 61/8 din' sdr-21 PVC
Company Name
30 /, 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ( Ly 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:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural fMunicipal/Public • ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential 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 0 ft. 20 ft• bentonite poured
Monitoring EIRecovely ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
� 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Et Salinity Barrier FROM _ TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology Et Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) �Otther(explain under#21 Remarks) ft. �/ ft.13 �//,C
4.Date Well(s)Completed: f 0 "Well ID# ft. (/ To ft. [/1L(,a /� d , r...k,
r (/U� 1
Sa.WellLocation: ft. </ ( ft. (ol-/f) e,s0C
i-,) / 7 10 � ft. ZaOft. l 106r ,,.1,fe
Facili /Owner Name Facility ID#(if applicable) ft. ft.
'Le 1) //a/ ad ft. ft. E E V
Physical Address,City,and Zip ft. ft. n ,
(2-0-
JF ) � / 21.REMARKS DEC 0 5 2023
County �/ Parcel IdentificationNo.(PIN) inforrria°iCn tPrs,c t xaa L14Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: WedeciG
(if
`well field,onnee�lat/lon is sufficient) ( �]�/ 22.Certification:
")./0 /0 -'-'3d-9-2
6.Is(are)the well(s)JPermanent or Temporary Signature of Ce fied Weil Contra Date
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: DYes or jNo with 1SA NCAC 02C.0100 or 15A 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 fonn.
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: po (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depthsifdifferent(example-3nd 2@100) construction to the following: I
10.Static water level below top of casing: y0 (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 Iform 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 SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) c Method of test: air 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: lJ ' 3 'u� completion of well construction to the'county health department of the county
where constructed. I� '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016
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