GW1--01569_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: y
14.WATER ZONES
WellContractorName FROM TO DESCRIPTION
Z Zfas ft. �`r) ft. S( Ya,
J��`�'-� S ft. 43 ft. dt 0,,c
NC Well Contractor Certification Number r�
'15.OUTER CASING(for multi- sed wells)OR LINER'(if ap licable)
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft- r\Vv ft. 61/8 in. sdr-21 PVC
Company Name !
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 'S�` SS-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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT ' '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL-PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ii b ft. Vc ft. reA '�v
4.Date Well(s)Completed `�`, Well ID# Is
ft. ks ft. k....,Yatn\Y`' edir• _
ft. ft. r-', 1� r I
5a.Well Location: 4 ,�lah an .4 `, i j
` - 1 JR �j b 1�- pq� R �ryA
.0 1 J 1--411 Uz O c. ft. vs-r.� ft. ce IVI�� 1➢ t!OL`Y
Facilii�ty//OO• wner�Naymee (� 1 Facility ID#(if applicable)b VO J ft. , ft. �` , � C'J
�\J'l) v`�7 b� \ dll(�� C�T�V�S \�i C7g��L) ft. ft. tny`t^.r;-r .;'' .yc;dirty L
Ph sical Address,City,and Zip ft. ft. Ctildr' DOG
`( ( cy `OS 21.REMARKS
County V��l Parcel Identificat`ionNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) l 22.Cer''cation:
P .
2--/s( .9
6.Is(are)the well(s)OX Permanent or DTemporary Signatur C ificd Well Contractor Date
By sign' tl form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or XDNo with 15A NCAC 02C.0100 or 1SA 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: S�� (ft.) 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:
10.Static water level below top of casing: IAr (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 Cent;r,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 C7` Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: `�t/ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016