GW1--07855_Well Construction - GW1_20231205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
a`��ic0 -0, 14.WATER ZONES I
��ll FROM TO DESCRIPTION,
Well Contra for ame%1 '/� ft ft.
{[ ft. ft. 1
CertificationNC Well Contractor Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
Morgan Well & Pump, INC FROM TO DIAMETER; THICKNESS MATERIAL
. 0 ft. t _5 ft 61/8 in' sdr-21 PVC
Company Name �7 closed-loop)
2.Well Construction Permit#: 5 16.INNER CASIN OR TUBING(geothermal FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC.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 ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial J Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 20 ft* bentonite i 6r r' 1, r
Monitoring Recovery ft. ft. 0 L.L .n a- i
Injection Well: ft, ft. a
Aquifer Recharge 0 Groundwater Remediation 1 F G 0 5 2 a2 3
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Banier FROM TO MATERIAL II AC M vT• THOD
ft. ft. h SC.;riti.a;IC I1: :teElirwr:$ Rt1
Aquifer Test Stormwater Drainage Dv OM A
Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) �,� ]
a ft. go ft. ae4 1. ( :r�
4.Date Well(s)Completed: / ....( 0Z3Well ID# ft. 7 ft.
5a.Well Location: 2Zv ft. a ft. / /O /) (Z71 t1.' i
p/ �p J 7 ft. 7 ft. lI (6,4
i4L•``7 LQ
�l�7 �� �`�.(r✓l..f � � ft. ft. � ��
Facility/OwCnerName Q Facility ID#(if applicable)
lSJ jdUt/ -y/ c r ft. ft.
ft. ft.
Physical Address,City,and Zip
.- f 4 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
. (if well field,one lat/long is sufficient) 22.Certification' J.C315 Q ...z
3 66/6.5“ N -0. 73.v L I3 W
6.Is(are)the well(s) Permanent or 0 Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby cer•tifii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EiNo 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 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 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:1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd jerent(example-3 rer 200'and 2(4)100') construction to the following:
10.Static water level below top of casing: 5 0 (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.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) ) 0 Method of test: air 24c.For Water Supply&Inlectioni 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 2 Amount: C. " J -- completion of well construction to the bounty health department of the county
where constructed. � '
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016