GW1--01387_Well Construction - GW1_20240304

• r Print Form 1
WELL CONSTRUCTION RECORD(GW-1)' For Internal Use Only:' I
1.Well Contractor Information: .
3U1 .14.WATER ZONESa``:
Well Contrac ame FROM TO DESCRIPTION
i(OJ ft. ‘,Gigft. pl
ft. ^5Ss ft. Q
NC Well Contractor Certification Number 15:'OUTER4CASING,(for mbihD-ca wells)OR LINER'(d.aji'timbre) ``
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name p ft. tik ft. - 61/8 i in. sdr-21 PVC
22 ���"�y, 16.:INNER CASING'.OR TUBING(geothermal closed=loop)::: .` '.'
2.Well Construction Permit#: g '�J V \\\� 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 DMunicipal/Public ft. . ft. in.
Geothermal(Heating/Cooling Supply) FEResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring ' 0Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology JSubsidence Control ft. ft.
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Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additiolial•sheets if necessary) ' ' '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
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Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) o ft. tS ft. Y I a -k
4.Date Well(s)Completed:o"t5 ( 4i Well DO 1s ft. it 6 ft. Lria4,0, Awk.
5a.Well Location: 46 ft. 55 ft. "��ow.% rot,
t'\/Orre. ,sresio, , 55 ft. 3(0S ft* b1ve. ityalle,Lt-e,
Facility/Owner Name Facility ID#(if applicable) ft. ft. J
!k Tf ,,) r* C -v-e.,r NC- P-863r7 ft. ft.
j
Ph sical Address,City,and Zip T
ft ft.
YOII`AN 1Qbrid't+ 21.REMARKS :...
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R'-'..G
(if well field,one lat/long is sufficient) 22.Certification: 1
-3 .SL`\o N i C�/ \.0 W MAR 0 A 20Z4 �� ��
r e f Certified Well Con�gclot pint I at
6.Is(are)the well(s)gPermanent or Temporary III�Vu7SctF� rf�iy V
B gning this form,I hereby certify that dgliPg(were)constructed in accordance
7.Is this a repair to an existing well: DYes or- jNo with 1SA 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 fonn.
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: 3125 ft.
P ( ) 24a. For All Wells: Submit this form 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:
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10.Static water level below top of casing: (ft.) Division of Water Reso I 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 Infection 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _1 O 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: )507_ completion of well construction to the county health department of the county
where constructed. I
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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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