GW1--02192_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (G W 1) For Internal Use Only:
1.Well Co actor Inform tion:
ad.
la.WATER ZONES I
Well Contractor ame FROMR TO DESCRIPTION
!cj ft an� ft. Ol�
3 aD ft Ain ft. S �'p i
NC Well Contractor Certification Number 4,OUTER CASING(for m ti-casOdwe�lls)OR LINER(if ap livable)'
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Morgan Well &Pump, INC FROM TO - DIAMETERt THICKNESS MATERIAL
0 ft 1 k ft. 61/8 in'' sdr-21 PVC
Company Name ►d-i
16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit II: 309434 i 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.
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Water Supply Well: 17.SCREEN
FROM TO ; DIAMETER- SLOT SIZE THICKNESS MATERIAL
QAgricultural fMunicipaUPublic ft ft. • in. •
Geothermal(Heating/Cooling Supply) ggResidential Water Supply(single)BI
ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT •
f Irrigation . FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 20 ft- bentonite I poured
Monitoring ORecovery ft. ft.
Injection Well: •
ft. ft. •- -
flAquifer Recharge • 0Groundwater Remediation • ______
19.SAND/GRAVEL PACK(if applicable)
(Aquifer Storage and Recovery 0Salinity Ranier FROM TO , MATERIAL ' EMPLACEMENT METHOD
Aquifer Test InStormwater•Drainage ft. ft.
I Experimental Technology •Qil Subsidence Control ft. • ft.
Geothermal(Closed Loop) QTracer •20.DRILLING LOG(attach additional sheets if necessary) - • •
FROM - TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
ft 15.
ft Pea dl�t
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4.Date Well(s)Completed:3 1 666 l Well ID# `S ft. O ft �rOW h L+ 1
5a.Well Location: 3� ft �� ft nre4 riCrk •
5 45 ft. t+l0 ft. Sa•
l i
Facility/Owner Name I A 1F_acility DA(if applicable) , (tall ft �l t) ft i, Wv, ;roG�.'
• 5 l' elltr J � IT r 'Or. IV , 1�ld*�. 5 Ibb ft 505ft .'Irdg •-7---:- r7‘^,-
Ph sicalAddress,City,as p ft ft - �,,,n I:_ as 1.:u
Physical
551 A "Sr7 21.REMARKS •
APR u$ 2024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i nii„r art:' 7 ?'' =ti r:'3 Uii
(if well field,one lat/long is sufficient L)e'l:Y x3 J(,:
) 22.Certification:
35.(A 40 N 7 ,'1c�g3 W �7�
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6.Is(are)the well(s)JPermanent or Temporary
Sian e.' edified Well Contractor Dat
•is form,I hereby cent that the well(s)was(were)•constructed in accordance
7.Is this a repair to an existing well: QYes or 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: 555 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list All depths ifd/fferent(example-3@200'and 2@100')• construction to the following: 1 • -
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10.Static water level below top of casing: L t (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 /$' (in.) 24b.For Infection 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: 1 ,
(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'1Ra1eigh,NC 27699-1636
13a.Yield(gpm) So Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one rccipY of this form within 30 days of
granulated chloine
13b.Disinfection type: Amount: r bZ 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