GW1--02182_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: I ;
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1.Well Co actor Inform tion:ntr
O d[ 14.WATER ZONES • •
Well Contractor. ame FROM TO DESCRIPTION,
3166‘ �r�;ft IcA ft. Q
ft ft. V i
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)' •
Morgan Well&Pump, INC FROM DIAMETER THICKNESS MATERIAL _
0 ' ft. "t4 ft 6 1/8 !in! sdr-21 PVC
Company Name DDOD
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: i Db\ T1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,Stale,Variance,etc.) ft. ft. in.
. 3.Well Use(check well use):' ft. ft I in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
In Agricultural •Municipal/Public ft. ft. in. •
QGeothermal(Heating/Cooling Supply) /j'Residential Water Supply(single) ft ft in.
fi Industrial/Commercial • (Residential Water Supply(shared) :18.GROUT '
�j�Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft zo ft bentonite ' poured
Monitoring QRecovery ft ft.
Injection Well: •
Aquifer Recharge 0 Groundwater Remediation • ft. ft.
19.SAND/GRAVEL PACK(if applicable)
(Aquifer Storage and Recovery OSalinity Bander FROM TO MATERIAL EMPLACEMENT METHOD
f.••Aquifer Test fStormwater Drainage ft ft.
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Experimental Technology .0 Subsidence Control . ft. • ft.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary) . •
FROM ' TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
0Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
C" f. IRI ft kr vE-- .
4.Date Well(s)Com leted• •
\\ )* Well ID# ft ft (f 1
P d q-0 b`(t-Nriotn Ilt4
Sa.Well 1Location: h (� rj ft ft oy.^
C ,t OC, 3Q.v� •
''-i W '� P41(* q5 ft 1t r ft irLt.,; C�tr(�0 tSct
Facility/Owner Name Facility ID#(if applicable) ft ft. I' �J_ h
t`-' a.50 Y"e,st-1 tAt) („Y` lie .t'J£•
- ft ft. , _. �4
p
Physical Address,City,and Zip �j r ft ft
n i(J �t�t� ( 21.REMARI{S r APR i�l1 C1 61 2024
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County Parcel Identification No.(PIN) i In`: "I':-_--I •.-,._,.a i j•'
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t `' r W J4]
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(if well field,one lat/long is sufficient) �y Cj • 22.Certification: •
/ //�i r (t
6.Is(are)the well(s) Permanent orI Temporary Sign e.• edified Well Contractor I. D Date
gt its form,I hereby certi'Mai the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or > J 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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details orwell
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'A OS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2@100). construction to the following:
10.Static water level below topof 4 casing: (ft.) Division of Water Resource`s,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: +
(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) (g Method of test: air • 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submif one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: ROOZ 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 1 - Revised 2-22-2016
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