GW1--00887_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�IYa 14.WATER ZONES I. '
Well Contrac Name FROM TO DESCRIPTION,
?�2
k"Da_ G ft ?a.3 ft. ago 1
tGzA ft. Sx ft. Cam '
NC Well Contractor Certification Number 15.OUTER CASING(for multi--cast Wells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
•
0 ft. 112 ft. 6 1/8 i in• sdr-21 PVC
Company Name ll
((�� /� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit It:: l W)E'"Z: 3-W`n L 9- 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.
17.SCRE •
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o . 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. i
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/raek type,grain size,etc.)
Geothermal(Heating/Cooling Retum) °Other(explain under#21 Remarks) G ft. zc, ft. r (v
4.Date Well(s)Completed:I `kS t3To Well ID# 2.6 ft. So. ft. .t..) dirt-
5a.Well Location: S6 ft. (1) ft. r ,J !
C �,y_ IV- cp ft. tot,
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ft. kwvi, sac�(VIA .c
Facility/Own ame Facility ID#(if applicable) le]p ft. S ft. iMl ` ro h Jr.l�J1
V`�1 VA-Yv�+C Y 1�t1
q 1nL1�Ya tic ZssiC ft. ft.
Ph sisal Address,City,and Zip ft ft. •
ffr••
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f1 r l)`N21.REMARKS U",. T-'`. "e r;, !i 1
2qn
County Parcel Identification No.(PIN) '
rEo 0 5 Z024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer'fication: ln%,I fti:K C.D r�� .,.5,•!ng U
Ss. L117 N 4/0 AgS4 W 7L
/ MOB0i3 1 l I '?.,t
6.Is(are)the well(s)MPermanent or °Temporary Signa Certified Well Contractor Date
By signing this form,I hereby o'ert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: •Yes or No with 15A 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. I
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: 54AS (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 J (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.) •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) E6 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: CZ_ 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