GW1--00838_Well Construction - GW1_20240205

1
1 .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
-3-6iV I
1.Well Contractor Info, ation:
14.WATER ZONES 1
Wel1Cot torName FROM TO DESCRIPTION. •
s< 1 �) ft. ft. I
u t`" ft. ft. I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, I I^I V C FROM ,.T,O DIAMETER I I THICKNESS MATERIAL
0 ft• 1(0 ft 6 1/8 sdr-21 PVC
Company Name � n�U
gq (�( 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, 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 ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• bentonite poured
❑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 ❑StormwaterDrainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft. i
•
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size eta)
tr / ft. ft. eui1,,d*4-
4.Date Well(s)Completed: I-L�`J' 17I WeII mil f
t.ft. ft a4 4l J p
. Sa.Well Location: ft. i ft. ,O IT(AA i1 r,/'u
Pqn.dal) eirfA bb
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l ad 3 `,jy/8 //17/ ft. ft 4. t. f 1, G.
Jam,.,ll�<// �liJ G=7 j�.�
Physical Address,City,and Zip
ft. ft. i, `t '.,ri.rs.ILA I. tia
/1 _ v�A 21.REMARKS FEB 5 %O n
County !ly Parcel Identification No.(PIN) t
5b• .Latitude and longitude in degrees/minutes/seconds or decimal degrees: 411"r'ry ^• `
well field,one lat/long is sufficient) L.:, r
(if wry 22.Certification:
{ ['
il 1 ) -..-z„.<3-zy
6.Is are the wells: CJPermanent or ❑Tern ora Signature a Oiled Weller f r I Date
Is(are) () P ry
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owher.
repair under#21 remarin 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
r 7 10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary 24c.For Water Supply and Open-Loop,Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine �j J�
13b.Disinfection type:_ Amount: L� C, '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018