GW1--02911_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W lI Contractor Information:\ZAA 14.WATER ZONES { '
Well Co torNama FROM TO DESCRIPTION
3 ,. f�I ,rn
ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable) •
Morgan Well& Pump, INC FROM 4O DIAMETER THICKNESS MATERIAL
0 ft. � ft. 61/8 'in' sdr-21 PVC
Company Name _,C�- /�.1(10.A.
A 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it:
W:�, � CO\I$ 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
InAgricultural 0Municipal/Public ft. ft. in.
ElGeothermal(Heating/Cooling Supply) *Residential Water Supply(single) fr. ft. in.
DI IndustriaLfCommercial Residential Water Supply(shared) . 18.GROUT '
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft• bentonite poured
Et Monitoring (Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation .
19.SAND/GRAVEL PACK(if applicable)
DIAquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ClAquifer Test • 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if rieces'sary)
Geothermal(Heating/Cooling Retum FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)(H g/ 1g� )r•
[]Other(explain under#21 Remarks) Q ft. �� ft. ��
4.Date Well(s)Completed: l 15 1••-1 Well ID# (,1 ft. +1 iti ft. ksybuly% AA
5a.Well
`Location:
�/ 71ft 352.
ft bY � YNOC/��/y���k
L\J 4`` `AJ� 35 ft. ft tv't,t3vl f(J�+T�� U
Facility/Ow�n/erName Facility ID#(if applicable) ft ft. J
(J!' l5 ‘n LL-riri.1 C.,akarti, 'c ft. ft. ` �
� �j .v u.f .i A
i lJ ,t .'.
�i O""" ft. ft.
P sical Address,City,and Zip
21.REMARKS IViAY t f,'4 L024
County Parcel Identification No.(PIN) - u.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: is'.K C�'r 3
(if well field,one lat/long is sufficient) cJ 22.C tification:
3 :3a-fo5 N go.qSJb3 w /
6.Is(are)the well(s)MPermanent or DJ Temporary Sign a Certified Well Contractor DM
B gni is form,1 hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or jNo with 15A NCAC 02C.0100 or 15A 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 INSTRUCTIONS
9.Total well depth below land surface: �XS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 14° (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 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 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) , ' Method of test: all- 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: D a� completion of well construction to lthe county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016 '