GW1--02160_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Wefix
Co actor Inform tion:
•
Oaa 14.WATER ZONES
Well Contractor ame FROM !T'�O DESCRIPTION
��5 ft. l% ft.
t s t
-�K `.�.'Cl ft aik^ ft. n
NC Well Contractor Certification Number 15. 01
�OUTER CASING(for multi-ca wells)OR LINER(if ap licable)'
Morgan Well &Pump, INC FROM TO - DIAMETER THICKNESS MATERIAL
0 ft `s5 ft 61/8 in. sdr-21 PVC
Company Name
� ��- �, �,-P, _ F .INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: -- 'fTO � FROM TO DIAMETER THICKNESS MATERIAI.
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: 19.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL _
El Agricultural f Municipal/Public ft. ft. . in.
0Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft. ft. in.
fI Industrial/Commercial • OResidential Water Supply(shared) . 18.GROUT • •
f hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: o ft. 20 ft bentonite . poured
DMonitoring DRecovery ft. ft.
Injection Well: .
EAquiferRecharge • El Groundwater Remediationl • ft. ft.
©Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable) •
I quif g El Salinity Ranier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStonnwater Drainage ft. ft.
Experimental Technology �Ij Subsidence Control . ft. • ft
Geothermal(Closed Loop) 0Tracer '20.DRILLING LOG(attach additional sheets if necessary) .
FROM ' TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
n Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) a'
b ft tO. ft re.c4 Vl-
4.Date Well(s)Completed:3 I I A Well ID# 10 ft 3o ft )0&Lelt" A`- L .
5a.Well Location: 30 ft 175 ft Lroot., rack.-
. 15 ft. 1,65
,6 5 ft
si va
Facility/ caner Name Facility ID#(if applicable) • 105 ft ` 'S ft R l'f bYk•_uIXA• -._
k1.s ft 1._p�j kG��'cl'rA
-. -- --
P``h sisalAddress,City, d i ��(( a �/ {� ft ft. i
,i+Y �[10�0 r�I L 0`3 21.REMARKS
APR Off 2024
County Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal-degrees:
(if well field,one lat/long is sufficient) ' �y" -r.
22.Certification: V u l L% uL(,� .
5. (0)36 N 1O,$4lg w W________7,
6.Is(are)the well(s)JPermanent or Temporary Si a ertified ell Contractor Date
is form,I hereby certify that the wells)was(were)•constructed in accordance
7.Is this a repair to an existing well: QYes or a No 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: 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 ate) 00'gild 2@100')' construction to the following:
10.Static water level below topA
of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: ! •
. (ie.auger,rotary,cable,direct push,etc.)
l
Division of Water Resources,
Underground
Injection Control Program,
FOR WATER SUPPLY ry WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `V 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: \b%Z. completion of well construction to the;county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016