GW1--02886_Well Construction - GW1_20240510

•
WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
1.Well Co actor Inform Lion:
JJJ
�d 14.WATER ZONESrOdd FROM TO DESCRIPTION 1
Well Contractor ame ''�h ft. 4a ft.
3 �aFV ft. ft. yrrY1
NC Well Co" nhactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)'
•
Morgan Well &Pump, INC FROM TO - DIAMETER THiCICNESS 1 MATERIAL
0 ft. ft. 6 118 in. sdr-21 PVC
Company Name 16.INNER C s OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: TJ `
�S`,,?�(rlJ��S� 331°6 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) •
ft. ft. in.
3.Well Use(check well use):'
17.SCREEN .
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL _
If Agricultural EiMunicipal/Public ft. ft. • in.
11 Geothermal(Heating/Cooling Supply) ligResidentfal Water Supply(single) ft. ft in.
*Industrial/Commercial • °Residential Water Supply(shared) .18.GROUT -
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
ii.Monitoring °Recovery ft. ft.
Injection Well: • ft. ft. •
X'Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery °Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD
ilII Aquifer Test 0 Stormwater Drainage ft. ft.
S Experimental Technology ©ISubsidence Control ft. • ft.
1 Geothermal(Closed Loop) °Tracer -20.DRILLING LOG(attach additional sheets if necessary)
FROM - TO DESCRIP ION(color,hardness,soil/rock type,grain size,etc.)
_'Geothermal(Heating/Cooling Return) nJ Other(explain ender#21 Remarks) ft b ft �,y `,,L
4.Date Well(s)Completed:/ �4 Well ID# `( ft. 3tS ft. �-o (�\
` *sot ft. ft. J� co�
•
5a.Well Location: 'ft. 45 ft ^9jy ey
Facilitye.
ID# ifa applicable) J ft. ft �3JJ �,J
Fa ility(f/,,O,,vn�rName__ 11����(1(� �,,(_ aivt'( PP ) r�'�-11bV Wy Ul \G 20f 1 ft. 1';ri, .^', ,,► 1a ,,i-` ;I.
` ft. �,{n
P�hysicalAddress,City,and Zip t' / 1 MAY j 2024
` : eill U?/I_tx3- elti? f 21.REMARKS
Par1celIttdentificationNo.(PIN) ' .` =•- .i
County D4' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
" (if well field,one'at/long is sufficient) 22.Certification:
'Z3 N lb All to w
Sign es ertified ell Contractor Date
6.Is(are)the wells)fhPermanent or Temporary
is form,I hereby ce lt&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or NON° with 15 CAC 02C.0100 or I5A 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 fonn. 23.Site diagram or additional well details•
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
1
9.Total well depth below land surface: '[ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3a 00'and 2Qa 100)' construction to the following: j
10.Static water level below top of casing: (ID (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/$ (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:
(i.e.auger,rotary,cable,direct push,etc.) 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) t 5 Method of test: air 24c.For Water Supply&Iniectii n!Weils: In addition to sending the form to
_ the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine OZ. completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constricted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Reviled 2-22-2016