GW1--00829_Well Construction - GW1_20240205

Print Form';: '
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContrFtor o
tr.
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
0150 ft. ass ft. l I
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
Morgan Well&Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 59 ft. 61/8 j t�' sdr-21 PVC
Company Name
n�� 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: 314 Nl 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural 0Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
DIndustriallCommercial • DResidential Water Supply(shared) 18.GROUT
IItrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring QRecovery ft. ft.
Injection Well:
. ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
QIAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• DAquifer Test f Stormwater Drainage ft. ft.
DExperimental Technology gip,Subsidence Control ft. ft.
0Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
V ft. Ls ft. Y.6, a;vri:r
4.Date Well(s)Completed: (( 12-j )4 Well ID# t5 ft. 35 ft. ';Irtxah Itvt....
5a.Well Location: 35 ft. 56 ft. y 3h 1(bG�.
• G F- velo exy� 56 ft. .� !O fL `.A�U•ti c h t L
•FaclIility/OOwnerNaName Facility F #(if applicable)� c r/ ft. �-b ft. i
NCI 1 e>'c -tv k b{I rVL GO ( ft. ft.
Ph sical Address,City,and Zip `C ft. ft.
titer -, 7d's A 66 k 21.REMARKS 1... .-f t• k III 1
County Parcel Identification No.(PIN)
ri=d; O 5 'Z024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
' (if well field,one let/long is sufficient) 22.Certification: lien
L 3�`t0 N SS•�� W D�,--;:..1. 3:?•�
,o
At ?L DIN E., OG t 115/a-q
6.Is(are)the well(s) Permanent or Temporary Sis4ofCertified Well Contractor Date t
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: JJYes or jNo 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:
• ''P. You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same donstruction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 2-6 (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: LA° (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.) I
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) f Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
I/� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 0 C117-- completion of well construction to the county health department of the county
' where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016