GW1--02193_Well Construction - GW1_20240408

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: 1
1.Well Co actor Inform lion:nicr
ad14.WATER ZONES I '
Well Contractor ame FROM TO DESCRIPTION
14/ ftl53 ft-
t l. .-gpw,
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licabley '
Morgan Well&Pump, INC • FROM TO - DIAMETER! • THICKNESS MATERIAL
0 ft. C6 ft. 61/8 !n'I sdr-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: {Ca-- FROM • TO DIAMETER' • THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):' ft. ft. in.
•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL
X Agricultural DMunicipal/Public g, ft, •in. •
X Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
*.Industrial/Commercial • DResidential Water Supply(shared) •18.GROUT •
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. bentonite I poured
IX Monitoring QRecovery ft ft.
Injection Well: .
ft. ft.
*'Aquifer Recharge 0Groundwater Remediation •
19.SAND/GRAVEL PACK(if applicable)
•I Aquifer Storage and Recovery EilSalinity Barrier • FROM TO MATERIAL ' EMPLACEMENT METHOD
*Aquifer Test fStormwaterDrainage ft. . ft.
*Experimental Technology 0 Subsidence Control ft. • ft.
it Geothermal(Closed Loop) 10Tracer •20.DRILLING LOG(attach additional sheets if necessary) - •
_'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO .DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. ,0 ft. 1P4 clIr F
4.Date WeIl(s)Completed ,Ia-L� Well ID# `° ft. ft. �rUW�3� ;A)r�
.
5a.Well Location: 30 ft. ft.
5brawn, . Yac,k
\c w-*v 'vx d S5 f t a.o st• •bl,� �r ,,e .
Facility/Owner Nam Facility 1D#(if applicab •le) - -A
46 o C 0 �.1.� �E1 W Cl I'('•c q( ft. ft 'ti L., :..:"a,._i',3 2....,'may-
Physical Address,City,and Zip ft ft APR
n 0§ %024
RbLikiLY Q1 p l3 01l 21.REMARKS . . . Y R 'J
County Parcel Identification No• .(PIN) T4`.� = ''''`` °( "�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: .
35. II,r1 N 10,58,1 b W 3( o 4
Sign e.• edified ell Contractor Date
6.Is(are)the well(s)MPermanent or Temporary b
1•its form,I hereby cer•tI that the well(s)was(were)-constructed in accordance
7.Is this a repair to an existing well: DYes or ram)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: ai (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100). construction to the following:
10.Static water level below top of casing: 35 (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.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,; leigh,NC 27699-1636
13a.Yield(gpm) 6)-- 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 chlorine OL completion of well construction to the c i un health department of the 13b.Disinfection type: Amount: p ty p county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016