GW1--00862_Well Construction - GW1_20240205

P.000f.,01
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
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14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
V5c6 ft. ft.
1
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if ap &able)
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. 61/8 . in' sdr-21 PVC
Company Name `A�SJ
�/ A� ^����ey 16.INNER C G OR TUBING.(gebthermal dosed-loop)
2.Well Construction Permit#: '� G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN :
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
0Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft. in:
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
IlInigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft• bentonite poured
Dl Monitoring EiRecovery ft. ft.
Injection Well: ft. it
0Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Batrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Eli Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTI N(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) °0Other(explain under#21 Remarks) 0 ft. ift
rj
4.Date Well(s)Completed: )2 "3 Well ID# co ft. ft. ro�/l j
/r ft. ft �/LyJ_ �„�Sa.Well Location: I/5J//�b/J /�(J/fD�/�t /�y^� O2e)41918� ft. 4t. L e, Cji/t/Y1� t
Facility/Owner Name Facility ID#(if applicable) ft ft.
f, __e / ft. ft.
Physical Addrrreess�City,/and Zip ft. ft.
j.'
L�'�1G' 11 21.REMARKS g _ •- A �'- ,a✓r,• :.
County Parcel Identification No.(PIN) I i—d a 5 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif infai Ci) 'rut-.--::1.;;;0 i�lrN.
35-05 N'I. 3103 W Ut. Cu3C.1G tl2^ZP1/
6.Is(are)the well(s)MPermanent or EtTemporary 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:. DYes or ElNo 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 5' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp e-3@200 and 2@100) construction to the following: '
10.Static water level below top of casing: SO (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.) 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.) 1
Division of Water Resources,:Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) eigar L Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
Oz the address(es) above, also subniit I one copy of this form within 30 days of
granulated chlorine 5 completion of well construction i the county health department of the county
13b.Disinfection type: Amount: "ZI•
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016