GW1--01378_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
l.�ontractor Information: ` /J•
�b614.WATER ZONES
Well Con t rName FROM TO DESCRIPTION
S30.)-....k
315 ft.-a�r11 ft. � w',
aP
3q5 ft. 3 ft. 4,'��l
NC Well Contractor Certification Number 15.OUTER CASING(for mul�Lased Wells)OR LINER(if op'licable)
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. tiOjk, ft. 6118 i in' sdr-21 PVC
Company Name
Cal)
W'(�-s-� 16.INNER CASING OR TUBING;(geothermal closed-loop)
2.Well Construction Permit#:V� " 2 J t r:,C/J _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
DAgricultural 0MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
E m lndustrial/Comercial Residential Water Supply(shared) H.GROUT '
tttt
Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite , poured
0 Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ere)
/ (� r� .0 ft. t o ft r
4.Date Well(s)Completed:o� d'1 d"-'� Well ID# ,low ft. ft. jD'.0�� A\
5r.Well1 Location:.. [l c ,/� �.�►Jr 2D ft. '35 ft. oyowv Yo L.
ni. &oi `moo, `e-ove ^('�V� �, ft. 05 ft. ��V� (��1U0�
Fa.ality//Ow�nerrNName , O� t3/1
Faciliy ID#(if applicable)`` �/ ft. 1J ft. J
Y 't lb 'C,\ ' A Ake 1.Lf% 1 -ri ft• ft.
ft. ft.
Physical Address,City,and Zip (� n (�
- , eAi/� \1-DA_ L x��`�`'_ 21.REMARKS' i^ �:.' .�z , •
County Parcel Identification No.(PIN) ii 1,'-- L-i i�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - MAR :0 4 2024
(if well field,one lat/long is sufficient) 22. ification: L`t
3S•(0 Vti Nqr.) Cj{D W Infor aiien Prncwoje*lit4a3 1 ....,,kt
6.Is(are)the wellXs) Permanent or OTemporary Signat f Ce fled Well ContractorDate
By si this Pm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or XONo with 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 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 I 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: 4' 2 J ft.
P ( ) 24a. For All Wells: Submit thiss-form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 4.5 (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
13a.Yield(gpm) 6 Method of test: air 24c.For Water Supply&InjectionI Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine completion of well construction to tiie countyhealth department of the county
Disinfection type: Amount: �t P P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016