GW1--02910_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Co actor Information:
a
14.WATER ZONES ! '
Well Cont for am` /f, FROM TO DESTION'
_�-- Qs ft. g� ft. 6 5p
U ft. (� ft. VI
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well &Pump, INC FROM DIAMETER THICKNESS MATERIAL
0 ft 5. ft 61/8 m. sdr-21 PVC
Company Name ��A
pp `_' 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: C,J"11V E`- ) "-'0D`rt? FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernri (i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
)Agricultural )MunicipaUPublic ft. ft. in.
)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
9Industrial/Commercial Residential Water Supply(shared) . 18.GROUT •
(•Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• bentonite poured
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
)Aquifer Recharge )Groundwater Remediation
� 19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery, DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
)Aquifer Test )Stormwater Drainage ft. ft.
)Experimental Technology )Subsidence Control ft. ft.
Geothermal(Closed Loop) )Tracer' 20.DRILLING LOG(attach additional sheets if necessary)
RFROM TO DESCRIPTIQN(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) d ft 1 a ft red 11_.l_
4.Date Well(s)Completed:'('k t�� Well ID# . ?�• 5a.Well Location: l.d ft. 3S ft. �Y15W k Yo Lk.-
1>V lla- ii-CaUt 35 ft ft ny -
:acility/t,. -'Name Facility lD#(if applicable) ft. ft. J 1 i'i..,�.'it.,•, i I,/ L.y� a
g •,f''" , '4. 6. ft. ft. NMAy - n 2f174
P sisal Address,City,and Zip 2 ft 'ft.
�US 21.REMARKS lr,:vt,.r-.a,;.. ;i:C4,-:6: .:i'.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,oneon l/at/long is sufficient) 22.Ce cation:�� �]
35.3i-�0 N�0_�(b�-9 W -'L� (9_4 '
C
6.Is(are)the well __s) Permanent or ..i Temporary S' tut r ertified Well Contractor ' Date
si;al. this form,I hereby cer'tib that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or a No with 1 A NCAC 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 forth.
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: 5 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Ca 200'and 2@100) construction to the following:
10.Static water level below top of casing: 3 5 (ft.) Division of Water Resources,Information Processing Unit,
If water 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:
(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
13a.Yield(gpm) 4° 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
13b.Disinfection type: Amount: completion of well construction tolthe county health department of the county
where constructed. t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 '