GW1--00830_Well Construction - GW1_20240205

f. Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contr ctor Information:
`-rdd14.WATER ZONES I i
Well Contractor Na a FROM TO DESCRIPTION
3�2z 105 ft log ft. tO ^�
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 I THICKNESS MATERIAL
a ft se t f 61/8 I hi. sdr-21 PVC
Company Name
��� , 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I:in.
I
3.Well Use(check well use): ft ft. j in.
•
Water Supply Well: FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IiResidential Water Supply(single) ft. ft in.
Industrial/Commercial ' DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.-MOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Banier FROM TO MATERIAL - EMPLACEMENT METHOD
- Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessity)
Geothermal(Heating/Cooling Return) ._I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type,grain size etc.)
I '1 b ft. yo ft. Czd a�,�
4.Date Well(s)Completed:I I f l I >-%; Well ID# 2.0 ft. 4e ft.�r Iv*.
I �4S1S
Sa.Well Location: f ft. ft. eY0 win r��
�t`'LAQ)sd\ `fir\' �l i 5 ft. 200 ft: 41 ram{ i 3 Y,+h 1 .
Facility/Owner Name \Facility ID#(if applicable) 1 ft. ft. J
a��`�� ft. ft. - -.. 'v,. .
Physical Address,City,and Zip ft. ft. r_ E,,4„�7 U.,:,iii dr1 I-,,,:,'„-,
b rAL�. 3 A 634 21.REM ARI{S rCCJ J ti [�Z4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tn"'Til° ''?1 i�� `'`7'''' 1'i
(if--
2G Q� �jwellfield,one lat/long is sufficient) 22.Certification: D'`E"=0-G
6.Is(are)the well(s)0Permanent or Temporary Sigi 1e�Cerufi�e/d Well Contractor Date
By sign' 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 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: 2 0'(� (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: I
10.Static water level below top of casing: 3 a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centr,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,,i Raleigh,NC 27699-1636
13a.Yield(gpm) 4& Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit ode copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: Sol- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016