GW1--02912_Well Construction - GW1_20240510

1.. •.Frint. brm:;
WELL CONSTRUCTION RECORD (GW-1) For Internal-Use Only: •
1.Well runtractor Information:
TacAti 14.WATER ZONES I •
Well Contractor ante FROM TO DESCRIPTIONj
^ Q� ft. Q}� ft. t o I r
/}�` VQ ft `l] ft. 19`
NC Well Contractor Certification Number .
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Morgan Well& Pump, INC FROM T DIAMETER' THICKNESS MATERIAL
0 ft 44 ft. g 1k8 in. sdr-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:0444 —71',y5—CI^VCRI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 4 Q' ft. Li in.
3.Well Use(check well use): ft. V ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
Agricultural [Municipal/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) POResidential Water Supply(single) ft. ft. in.
f IndustriallCommercial DResidential Water Supply(shared) . 18.GROUT '
I1hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft bentonite . poured
Monitoring QRecovery ft. ft.
Injection Well:
Aquifer Recharge 0 Groundwater Remediation ft. ft.
A uifer Storage and RecoverySalinityDallier 19.SAND/GRAVEL PACK(if applicable)
4 g FROM TO MATERIAL EMPLACEMENT METHOD
ElAquifer Test 0Stormwater Drainage ft. ft.
)Experimental Technology in Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer• 20.DRILLING LOG(attach additional sheets if iieces'sary) •
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,t soil/rock type,grain size,etc.)
iIDft. as ft. jrislwvt C�`Y�4.Date Wells)Completed: $(I)J+. Well ID# aQ ft 3'0 ft. �altz h , I k
5a.Well Location: 3!� f! ftv� , 1�
fjow vd Otosk.h V ft. ft. T r
Facility/Owner Name FatcilityyID#(if applicable) ft. ft. . ..' +�,.__i jai 7� 1�'
9°�ac� Yl��rr . i`�Att2.5:WV6-.NL ftal+ . ft. MAY 1 0 2021
P sisal Address,City,and Zip 'p
GHQ 21.REMARK3 !T,:J: -.;:k:•;n .a-,1+-.G. -. 'i! ,iF
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onec lat/long� Q is sufficient) 22.C tification' 411P1—•
35.S(0 ` N O0 •�1!nV� W !%6.Is(are)the well(s)JPermanent or OTemporary Sirtified Well Contractor Dat
By signi o is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or }No with 15A 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 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: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 15 (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) 40 Method of test: air 24c.For Water Supply&Iniection 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: t� 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 '