GW1--02187_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co actor Inform( li]on:
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14.WATER ZONES
Well Contractor ame FROM TO DESCRIPTION;
ft. el
3 -P4 ft fp ft. ��L1
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)•
•
Morgan Well&Pump, INC FROM TO - DIAMETER I i THICKNESS MATERIAL
0 ft. 15 ft. 61/8- in. sdr-21 PVC
Company Name lv
M 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _ L 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: 19.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
•
['Agricultural ['Municipal/Public ft ft. , in. ' •
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
['I IndustriaUCommercial • ['Residential Water Supply(shared) . 18.GROUT
['Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: ' 0 ft 20 ft bentonite poured
['Monitoring ['Recovery ft. ft.
Injection Well: •
ft. ft. •
['Aquifer Recharge • ['Groundwater Remediation •
19.SAND/GRAVEL PACK(if applicable)
©I Aquifer Storage and Recovery ['Salinity partier • FROM TO MATERIAL , EMPLACEMENT METHOD
['Aquifer Test ['Stormwater Drainage ft ft.
i
['Experimental Technology ['Subsidence Control ft. • ft.
['Geothermal(Closed Loop) ['Tracer .20.DRILLING LOG(attach additional sheets if necessary) - -
['Geothermal(Heating/Cooling Return) ['I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. 24> ft r`{ciday+ .
4.Date Well(s)Completed:3 I;42(' Well LD# • ',© ft. Sc) ft. 4 r6u.UAW i
5a.Well Location: c0 ft.
15 ft iorviofr, rat i
'Dreio_ Makve r� s'ks ft -6S c� :. _
Facility/Owner Name `A i Facility ID#(if applicable) c r ft ft J '. "+ .,-,+'a60 % a9 a._,tl-_j
•V orei l Q VV el t t gtbl(c?tT ft. ft.
jft ft. APR 2024
Physical Address,City,and Zip
gRbLy ,
1 7 l 0.A 21.REMARKS
J • .. . ,a
County Parcel Identification No.(PIN) Ml.,;J C;
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. 14,1s. N 2o. sl,)Ip W
6.Is(are)the well(s)JPermanent or Temporary Sim edified ell Contractor Date
• is form,I hereby ceal(&that the'wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or No math IS• ,CAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall 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 he 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:' hC� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �uJ (ft.) 24a.For All Wells: Submit tills form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100)' construction to the following:
10.Static water level below top of casing: -4 (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: I .
(i.e.angel;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) Method of test: air 24c.For Water Supply&Injection WI lls: In addition to sending the form to
L the address(es) above, also submit one]copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: g'az completion of well construction to the cotinty health department of the county
where constricted.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016