GW1--02887_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well actor Inform lion:
Lintr
add. i
14.WATER ZONES
FROM TO DESCRIPTION ,
Well Contractor ante 3,15`t. Weito ft. 66 vri
3 N 1 ft ft. (��
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)' •
Morgan Well &Pump, INC FROM TO • DIAMETER; THICKNESS MATERIAL
0 ft. 17f7 ft. 61/8 Pb sdr-21 PVC
Company Name `
b✓Z3Z "�1 q ! 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 65W 1 i 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,I nonce,etc.)} ft. ft. in.
3.Well Use(check well use):' ft. ft. in.
1Water Su l Well: 7.SCREEN
PP Y F FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
•Agricultural QMunicipal/Public ft. ft. • in.
X Geothermal(Heating/Cooling Supply) IgiResidentfal Water Supply(single) ft. ft. in.
X Industrial/Commercial • DJ Residential Water Supply(shared) . 18.GROUT
i Inigation FROM TO , MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
X Monitoring DRecovery ft. ft.
Injection Well: • ft. ft. .
X'Aquifer Recharge • Q Groundwater Remediation .
19.SAND/GRAVEL PACK(if applicable) .
*1 Aquifer Storage and Recovery n Salinity lianier FROM TO MATERIAL EMPLACEMENT METHOD
XI Aquifer Test 0 Stormwater Drainage ft. ft.
•
X Experimental Technology Ej Subsidence Control ft. ft.
•'Geothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary) .
FROM TO DE,SSCRIPTIg11(color,hardness,soil/rock type,grain size,etc.)
Mg Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) b ft D...s ft. red u j!
4.Date Well(s)Completed Z. l J�i Well ID# ass. 45 ft. ,, a t4- •
Ay4Well Location: !!! ( 1'C ft �rjl� ft �t44.r M,L_/S-Q"� •
� �'C • cis ft. s ft. b1 i. l�4)
W ft. 7 ft ( { _
Facility/OrName FacilityID#(ifapplicable) �,�..rtT ,` _ '.,. uf.
.i
ft. ft. ; t �.•C. d�,r 'A. l.r
Physical Address,City,an Zip �]QJ� 2,4 Cos I ft I ft MAY 1 0 2024
T(t de, 6` 1417
l W r l 21.REMARKS '
County Parcel Identification No.(PIN) '“V:i CP3
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Certification:
35, (Q(Arl N I-Cl1O 4 W v2J
6.Is(are)the welI(s)J .lPermanent or Temporary Sign e.' edified ell Contractor Da
is form,I hereby cer•ti(y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or 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 INSTRUCTIONS9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths([different(example-3 2000'and 2 rQ+1001. construction to the following: i
10.Static water level below top of casing: 76 (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 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: r
(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,Raleigh,NC 27699-1636
i
13a.Yield(gpm) � 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: /3DZ 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