GW1--00833_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD•(GW-1) For Internal Use Only:
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1.Well Contractor Information: I
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W l{J : • 14:WATER ZONES I
Well Contractor time FROM TO DESCRIPTION
/��� ft. ft. I I
J
`- ✓ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased dells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM TO DIAMETER 1 THICKNESS' MATERIAL
0 ft i q ft. 61/8 I in. sdr-21 PVC
Company Name .
�� 9 7 '16.INNER CASING OR TUBING(geothermal dosed-loop): .
2.Well Construction Permit#: J L FROM TO DIAMETER THICKNESS ' MATERIAL _
• List all applicable well construction perlt is(i.e.UIC,County,State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. .ft. in.
Water Supply Well: • FROM l'
TO
DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural •• 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft - ft in. . .
DIndustrial/Commercial DResidential Water Supply(shared) :IS.GROUT . •
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .,
Non-Water Supply Well: 0 ft. 20 ft. bentonite I poured
Monitoring tpRecovery ft. ft. 1
Injection Well:
ft. ft. .
0Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable):
(Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. .. ft..
0Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) 10 Tracer 20.DRILLING LOG(attach additional sheets if riec"essaiy). ..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROMft. TO DESCRIPTION(color,hardness,soiBrack type,grain size,etc.)
r Vft. /Le- } I
4.Date Well(s) �1
Completed: � t..1� Well ID# ��ft co ft tt M�j A ,�1 I �'
5a.Well Location: { 1n ft.. (A ft. { A Vn�w `Lei
mo r It Sty MAc() 1 ft. tO;ft \ Cl fa ve-tei
Facility/Owner Name Facility ID#(if applicable) ft. ft.
.ki n.,C1 VD ,3( i)—(Mt ft. ft.
Physical Address,City,and Zip ft. ft. �I` (. .a d�i ar I;�
r� 'p.^ 21.REMARKS LY __'. r ., )'
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County , wV- . Parcel Identification No.(PIN) rCD ti ? [024
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;t:`;,;,',: :,;;";i c":i,. , ,
(if well field,one latdong is sufficient) 22.Certificati n: "'•` rJri:7
G
3S / I ' N D U � I L�J :p....2,,
r � 3 W �%%� 1 / t-t Y
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 jNo with 15A NCAC 02C.0100 or I5A 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: ..-7
o`'_ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q20,,0'and 2@100) construction to the following: 1
rr
10.Static water level below top of casing: �-i (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/8 '
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition'to sending the form to the address in 24a
rotary above, also submit one copy of this fdmi within 30 days of completion of well
12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) I
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 5 Method of test: air 24c.For Water Supply&Infection 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: ( ' S O Z. 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