GW1--02853_Well Construction - GW1_20240510

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only: . 'j
1.Well Contactor Inform Lion:
14.WATER ZONES I
Well Contractor ame FROM TO -DESCRIPTION
3P� 1� fts ft. III,11
1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)'
Morgan Well&Pump, INC FROM _ TO - DIAMETER i THICKNESS MATERIAL
0 ft. � ft. 6 1/8 in. sdr-21 ,PVC
Company Name
333 1 V 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: 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: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
•Agricultural fMunicipal/Public ft ft in.
II Geothermal(Heating/Cooling Supply) NiResidential Water Supply(single) ft ft. in.
X Industrial/Commercial • DResidential Water Supply(shared) 18.GROUT
i-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft- bentonite poured
•Monitoring DRecovery ft. ft.
Injection Well: •
ft. ft.
•Aquifer Recharge 0 Groundwater Remediation •
19.SAND/GRAVEL PACK(if applicable) —
III Aquifer Storage and Recovery O Salinity Bonier • FROM TO MATERIAL ' EMPLACEMENT METHOD
•i Aquifer Test D Stormwater Drainage ft. ft.
X Experimental Technology Subsidence Control ft • ft.
m Geothermal(Closed Loop) QTracer "20.DRILLING LOG(attach additional sheets if sieces"sary) - "
_'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM • TO DESCRIPTION(color,hardness,soil rock type,grain size,eta)
O ft. 'O, ft. �j J` .
4.Date Well(s)Completed:4 12Z� it Well ID# • `� ft. 30 ft. brow...,
``r
5a.Well Location: ft 45 ft L You y1 _A tir / S!„ •
•WAV 134 cS ft. 365 ft. 1j,7'1�� .Y vrA7 �?u
Facility/Owner Name Facility m#(if applicable) - 7 ft �) ft. v �(�Y
(• (elk re e....s ' 1( r4C- ZgIS/ ft. ft.
sical Address,City,and Zip ft ft !('ti �`^ r {' ,
,Van �(Ob 0S i`.` ,.
21.REMARKS. q
Parcel
- County Pal Identification No.(PIN) MAY n LQ�y
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees: Iv ' '- : , :1—^r -;•- •
(ifwell field,one'at/long is sufficient)) 22.Certification: L-'.P�i' (.a'3 C":"1
'''SS,S5cti3 N SO,'4y(d-1 W
6.Is(are)the well(s)JPermanent or Temporary Sign e.' edified ell Contractor Dat
Qi •is form,1 hereby certify that the'wells)was(were)"constructed in accordance
7.Is this a repair to an existing well: 0Yes or EINo with 15 CAC 02C.0100 or 1SA 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:' y 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 00'and 2@100`)' construction to the following: I
10.Static water level below top of casing: S (ft.) Division of Water Resources,tInformation Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (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 metho d: construction to the following: i
(Le.auger,rotary,cable,direct push,etc.) e
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) w 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: IA.ie. completion of well construction to the i County health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' ' Revised 2-22-2016