GW1--00861_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
2i,, ,,
14.WATER ZONES
WeIlCont ct rName FROM TO DESCRIPTION
115 ft. I Iff ft. Ie p%)ri
3`'4�A No ft. 1' z ft 0l
NC Well Contractor Certification Number
15.OUTER CASING(for multi-c ed wells)OR LINER(if ap livable)
Morgan Well&Pump, INC FROM TO DIAMETER, THICKNESS MATERIAL
0 ft. 10, ft. 61/8 .in' 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.UI , a ty,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 DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) +Residential Water Supply(single) ft. ft. in.
10 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT •
_
jhuigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . 0 ft• 20 ft' bentonite poured
Monitoring •fRecovery ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge 0 Groundwater Remediation _
19.SAND/GRAVEL PACK(if applicable) •
0Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0 Stormwater Drainage ft. ft. .
Experimental Technology 0Subsidence Control ft. ft.
0 Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary) . `
. f 6-iV Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cotLoq hardness,soil/rock type grain size etc.)
C3 ft. 2.0 ft. rr 1 4t
4.Date Well(s)Completed: � t� Well ID# ft. 35 ft.' b ri .
5a.Well Location: 35 ft. 5 D ft. bl h, roc.(
Powl! i'.
.ud��e, soft. 75 ft. Sivri,
r. v
Facility/Owner Name Facility 1D#(if applicable) 945 ft- 9 o ft
I'M ..,- Occd c4,1?-d4'la 1 Zcgzcif 9b ft. f 1v5 ft. 4�lur ;A reLkt .
ft. ft. i�
Physical Address,City,and Zip ��Z�/ / ,
. to nbo o J [-z'i- 1 8 21.REMARKS . - `
County Parcel Identification No.(PIN) t_1® ' ter, d� C:I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F C Ci T ^
(if well field,one lat/longissufficient) 22.Certification: 2024
in., a s.,, I11'N r„, _
6.Is(are)the well(s)JPermanent or Temporary - Sign/ b Certified Well Contractor ; OG
Dat I
By signing this form,I hereby cer•t that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JjYes or JNo with 11A NCAC 02C.0100 or 1SA 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 Ito 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 I
9.Total well depth below land surface: 16S (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: 45 (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/$ (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.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) (^1 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: le 6 i completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division'of Water Resources' Revised 2-22-2016