GW1--00888_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
3 0'Nr '10 1 f 14.WATER ZONES
Well Contract Name FROM TO DESCRIPTION
ft. ft.
L' 0)'-jaft. ft. I
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable)
Morgan Well &Pump, INC FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. Lam( ft. 6 1/8 in sdr-21 PVC
Company Name 'n 1 ���JJJ16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: C, `fir Wei",i vp �� 11/3 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) Or esidential Water Supply(single) ft. ft. in.
0Industrial/Commercial jtiResidential Water Supply(shared) 18.GROUT
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flhTigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
ID Monitoring DRecovery ft. ft.
Injection Well: - •
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
D. Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
'FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ri Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) r`, /bft. 5 `� ft. vV t, „ .,„..4.Date Well(s)Completed: 1—' 14 Well m# C ft. r Ll ft. i` `c 11066
� is W' I t-O
5a.Well Location: i
V r . ft. -1._ft.
ft. G�po j A
tQA/I S 1Pn4 _ ft. ft. J ; •
by
Facility/Owner Name
Facility ID#(if applicable) ft ft IT ^— . 7---,- --.
air �j�!✓ Ha,/�/ Li) ft. ft. ', '1 f �.
.v' ._�. F p� '
...ate
Physical Address,City,and Zip ft ft. I-C D I) 5 2024
Cathy/./ 21.REMARKS K }
County Parcel Identification No.(PIN) `��f.
..ICa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �/ /e �] 22.Certification: I
6 / j
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6.Is(are)the well(s)OPermanent or Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certtt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or EiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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: OG (ft.) 24a. For All Wells: Submit this forin 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: ;0 (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 fo'mi 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) Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit ode copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: CS' S 6 S` completion of well construction to the,'county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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