GW1--01380_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1-Xligi
ntractor Information:
`.CMd
14.WATER ZONES I
Well Contra Nan FROM TO DESCRIPTION
<-� a 51A ft. ( p O ft. /5 n 1 y�
J ft. ft. 'J1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. /�,]� ft. 61/8 In' sdr-21 PVC
Company Name WP
0S\V O 1 ' — 16, >< .INNER CASING OR TUBING(geothermal closed-loop)
CKNESS
2.Well Construction Permit#: -' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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
0 Agri cultural [Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) J i Residential Water Supply(single) ft. ft. in.
0IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
InInigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
(Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test IDStormwater Drainage ft. ft.
DExperimental Technology 0 Sub si den ce Control ft. ft.
DGeothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTI N(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) n,Other(explain under#21 Remarks)
0 ft. 6 5 ft. RA ,r�
4.Date Well(s)Completed:a'I��' '-'‘it Well ID# '�S ft. �`CJ ft. bywW� a,„,..4„,
fb
5 Well Location:
6 sS ft �(6 ft. L youyel ���
re. croakW1zS 50 ft. 50
5 ft. 17` _ �ccl..�L
Facility/Owner me ` _Fa}ciility ID#(if applicable) QP- ft. ft. �C r- ..-�.y,.,,. ,.'} r'i�_,ry•9
`k5 `o"_ RA (�A-t�,L'Sk1�,�k2� Alcz 17 1 1 ft. ft. ° 7 t�kJ ♦ 3 �1
Physical Address,y,and Zip MAR 0 f 2p24
rr i 1 . 4/11�Leo-cc:lg _
21.REMARKS
County Parcel Identification No.(PIN) hift^r iT.2.-iC+1 s-"• 'l 4 U
yo
DinCu` to
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrcah'o
olegCo N "��b W �� ?4
6.Is(are)the well(s)OPermanent or Temporary Sig :Certified Well Contractor _ _, Y
Da e
gr it,this form,I hereby cer•t that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or EiNo with 15 CAC 02C.0100 or ISA 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 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 U C�J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example- 5and 2Q100') construction to the following:
I
10.Static water level below top of casing: (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) 15 Method of test: air 24c.For Water Supply&Injection(Wells: In addition to sending the form to
the address(es) above, also submit dna,copy of this form within 30 days of
granulated chlorine completion of well construction to thie countyhealth department of the
13b.Disinfection type: Amount: p I P county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 '