GW1--01350_Well Construction - GW1_20240304

' Print Forrn` 7.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Y i '
1.Well Co tor Information:
`\v\ ,ut\A/l�� I 1 14:`WATER`ZONES =
Well Contractor FROM TO DESCRIPTION
Nam
�t\ Pt v1/4„43 ft. 'Ii1 r7 ft. )...psi N
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased"wells)OR'LINER(if an licable)
Morgan Well&Pump, INC FROM T8 DIAMETER THICKNESS MATERIAL
0 ft. /t.� ft. 61/8 I in' sdr-21 PVC 4
Company Name 2.Well Construction Permit#: -
-4:3-(1 v'16.INNER CASING OR TUBING(geothermal closed-loop)- `' S '.
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:SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) j1/t';iResidential Water Supply(single) ft. ft. in.
1.
Industrial/Commercial DResidential Water Supply(shared)
y 18.GROUT , .. >g" '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o - ft. 20 ft• bentonite poured
Monitoring ElRecovery ft.- ft.
Injection Well: •
ft. ft.
Aquifer Recharge D Groundwater Remediation
,`19:SAND/GRAVEL.PACK.(if applicable). : . '
Aquifer Storage and Recovery •Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. I'
Experimental Technology 0Subsidence Control ft. ft. •i
Geothermal(Closed Loop) Tracer 20:DRILLING LOG'attach additihiial`sheets if necessar
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft* ft.
4.Date Well(s)Completed: \-).6k; Well ID# b ft. ZO ft. jo�ow� Y-0
..Well Location: 'a� ft. ry ft. �f 1`
�'r r � -3, ft. kVUS ft. teed e rQoJc
Facility/OwnerWy/(\ Name Facility ID#(if applicable) ft. ft.
l
'1 -BY \N -X ft. ft. -
Physical Address,City,and Zip ft. ft.
4 (.414 el ep 5SOCYNZ )b3 ''z1 REMARKS ?:
County Parcel Identification No.(PIN) • ,t .CA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 ft
(if well field,one llat/longissufficient) 22.0 ''cation: 1' ~� 2024
Y5n &t/bO N 5S0 . 43 W 1r}ir?ii'f'w3twn ?f..;,. ; +',g g/�[T-
6.Is(are)the well(s)0X Permanent or Temporary
Signs o ertified Well Contractor ��� � Date
By s Wing is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or EiNo 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.
23.Site diagram or additional well details:
8.For Geaprobe/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: 40`, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(fferent(example-3@200'and 2@100') construction to the following:
1
10.Static water level below top of casing: 3S (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!enter,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 one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine, Amount: \i n_ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016