GW1--02118_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co actor Inform don:
ugr
Inform
14.WATER ZONES i '
Well Contractor ame FROM TO DESCRIPTION
3 -N )16 ft. I'13 ft. i• l i
NC Well Contractor Certification Number 15.OUTER CASING(for multi ased gldlls)OR LINER(if ap licable)'
Morgan Well&Pump, INC FROM TO - DIAMETER! THICKNESS 1 MATERIAL
0 ft. ft. 6116 1II' sdr-21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: iv A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permitsjUJC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):' ft. fr 'n'
Water Supply Well: 19.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
ElAgricultural JMunicipal/Public ft. ft , in. •
0Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
l Industrial/Commercial DResidential Water Supply(shared) . 18.GROUT
Irrigation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: o ft 20 ft bentonite poured
Monitoring ORecoveiy ft ft.
Injection Well: •
.
ft ft.
ElAquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL ( EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control . ft • ft.
Et Geothermal(Closed Loop) • (Tracer '20.DRILLING LOG(attach additional sheets if necessary) '
0 Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soillrack type,grain size,etc.)
1 Q Q ft 2.© ft ye dl'�•�
4.Date Well(s)Completed:,'1,�Io1� Well ID# ft 1.1 5 ft' bI CY(?ayL I Air
I- -
5a.Well Location: 1111 ` • 4%/,� ft 1i JO ft itsraubiA' a f ScuAd -
AtL�` tuwIkt� 'To
eft c( ��J�1.
Facility/Owner Name Facility ID#(if applicable) ft ft. J
ft ft
t LIS .
irv�lad 'D r (��1.Ic6r� �c. Z.�o�S �:...��:� ��w,4 ;;7 a.
Physical Address,City,sg i Zip ft ft. e"t
aunty21.REMARKS • !APR 1) ��
Parcel Identification No.(PIN) _ t .
it��.:.p-.,n�.i:I{ :•' `d':i*d:�'F�WIN
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
35.441A- N (S.54(), . W er 3
� Sian e.' ratified ell Contractor D e
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6.Is(are)the well(s)JPermanent or E Temporary 5
is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ell* No with 15 CAC 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 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: 44)-5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1/different(example-3@,200'and 2®100)' construction to the following:
10.Static water level below top of casing: ".5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (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
(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) 3‘!Z 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
granulated chlorineI 13b.Disinfection type: Amount: 1 ft. completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016