GW1--02858_Well Construction - GW1_20240510

.
WELL CONSTRUCTION RECORD (GW 1) Internal .Prim P151 !
For Use Only:
•
1.Well Co actor Information:
jat
•
�d 14.WATER ZONES 1 i
Well Contractor ame FROM TO DESCRIPTION
3 /� 5 , ft. ft.
•
NC Well Contractor Certification Number ft. ft.
Morgan Well&Pump, INC 15.OUTER CASING(for multi-cased well3)OR LINER(if ap livable)' •
FROM TO DIAMETER` THICKNESS MATERIAL
Company Name 0 ft i 10I ft I 61/8 lin: I sdr-21
�IDr7.g3 PVC
2.Well Construction Permit#: 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction permits(i.e.UIC,County, tate,Variance,etc. PROM TO DIAMETER THICKNESS MATERIAL
) ft ft. in.
3.Well Use(check well use):' ft
ft. in.
19.SCREEN
Water Supply Well:
0Agricultural °Municipal/Public FROM TO DIAlYfE7 • SLOT SIZE THICKNESS
ft. ft. in. MATERIAL
°Geothermal(Heating/Cooling Supply) firResidential Water Supply(single)
�IndustriaI/Commercial ft• ft. in.Water Supply(shared)
hTigation 18.GROUT • .
Non-Water Supply Well: PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 ft. Z0 ft bentonite poured
l.I Monitoring DRecovery
Injection Well: ft ft.
ft. ft.
•
'Aquifer Recharge DGroundwater Remediation .
°Aquifer Storage and Recovery 0Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
Aquifer Test FROM TO MATERIAL, '' .
�StormwaterDrainage ft, ft Fr1nLACEMENTMETHOD
Experimental Technology 10 Subsidence Control
ft. • ft.
°Geothermal(Closed Loop) 0 Tracer .20.DRILLING LOG(attach additional sheets if uecessa Geothermalry) .
(Heating/Cooling Return) Other(explain under#21 Remarks) PROM ' TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
( i4 �� Ki
4.Date Well(s)Completed: �I Well ID# ft. 5 ft. biotiola
5a.Well Location: ...45
1C ft. •In ft .bfistAle% Al.�
'Day, l i .t "'v • 'la ft t• ft
d.
Facility/Owner Name Facility ID#(if applicable) T� ft ft, h
& <t5rsssovi V •Physical
Address,City,and ZipVAb /.� ft. ft )O Z 4
a,v� " 1 JS 3 21.REMARKS • MAY 0L
•
County Parcel Identification No.(PIN)
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
•
.��� �v 22.Certification: .
N ,(Q 25 W
--
6.Is(are)the well(s)0Permanent or °Temporary Sign::,..• ertified ell Contractor
Dat
7.Is this a re air to an existing '/{g,i •is form,1 hereby cent&that the well(s)was(were)ronsh•ucted in accordance
P well: jYes or a No well,15• 'CAC 02C.0100 or 15,4 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1
SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: •
For multiple wells list all depths ifdifferent(example-3200'and 2Qa 100)' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well •construction to the following: .
•
10.Static water level below top of casing: 55(twofer level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit, •
6 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition to senlding the form to the address in 24a 12.Well construction method rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 air '
Method of test: 24c.For Water Supply&Injection Wells:
i
the addresses) above, also submit one co py addition to sending the form to
granulated chlorine
13b.Disinfection type: Amount: -� i of this form within 30 days of -
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