GW1--00825_Well Construction - GW1_20240205

Pnrit Form i y.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES 1. I
Well Contract&Name FROM TO DESCRIPTION
�cLUe J` -,^ ft. ft.
5/�, IV'1
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
0 ft. C]1 ft. 61/8 ln' sdr-21 PVC
Company Name J P
16.INNER CASING OR TUBING(geothermal closed-loop)
l (rb 2
2.Well Construction Permit#: II--- 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/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&AMO T
Non-Water Supply Well: 0 ft. 14 4 ft• bentonite .AGNrpd k tle,p 3
°Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
°Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION
"(c�olo^,hardnaess,soiUrock type,grain size,etc.)
1 D ft. �] ft. Y{) rt!,J l'I1�
4.Date Well(s)Completed: I 4 Well no //q� ft. 3V(_ ft. i) Go\iff) /)iM� 15a.Well Location: if ft. �} ft. 1�'/t 0 c�0 ]n,,
Co -H.CAki Odf f i5 ft. ft. ..
Facility/Ownerr /Name Facility 1D#(if applicable) ft ft.
CJ lG l.. Kt- / 1 ft. ft. I IT,.1 ^--4.,-., - -`
_ .;,
Physical Address,City,and Zip ft. ft. '"�*�w'" r`• VJ :
5-710'1 y
21.REMARKS ' !- L�`t
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f.if well field,one lat/long sufficient) v ''"�`
(� � is Cl j 22.CertiflicatiL�n: 3YH )/ /J
6.Is(are)the well(s)JPermanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or JG 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 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IPS (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:
10.Static water level below top of casing: �30 (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 rn.
( ) 24b.For Injection Wells: In additior 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 Cantl r,Raleigh,NC 27699-1636
13a.Yield(gpm)___ V 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: completion of well construction to the county health department of the county
where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016