GW1--03359_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
- C,N\ t\0� 5 . 14.WATER ZONES
Well Contractor Nam
FROM TO DESCRIPTION
ft. ft.
`-'1" J ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lleable)
Morgan Well & Pump, I N C FROM T DIAMETER THICKNESS MATERIAL
0 iL fr' 61/8 in' sdr-21 PVC
tEMU ..dmpanyNarne 1R
_V ,N _._n \ __^ lt_ Alw _
— on FROM =TO -III I -R �I'14IGI04Es 1�k�T'FRIi3ia,
2-.-Will Construction Permit# ���-��� ����.�
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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural DMunicipal/Public ft. ft. in.
(Geothermal(Heating/Cooling Supply) aiResidential Water Supply(single) ft. ft. In.
O IndustriaL/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. bentonite poured
Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
0Aquifer Storage and Recovery )Salinity Barrier FROM ' TO MATERIAL EMPLACEMENT METHOD
DAquifer Test Ell Stormwater Drainage ft. ft.
ID Experimental Technology DSubsidence Control fr. ft.
▪Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) f Other.(explain under#21 Remarks) 6 f ,,rr�
t. ii
ft' �"V' ` T` '
4.Date Well(s)Completed:_1 J� �� Well ID# ft. ft. (00\ i _c ('
5a.Well Location: (L- ft. Gi ft. ( ( r\1 fi e
�c? Clcttt Isw00 � ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Q P i ) ft. ft. L.�. ` . /r"
Physical Address,City,and Zip ft. ft.
1`\CS P\ 21.REMARKS .11..N 1 ( 424 _
Cotuity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
.3�i>135 N c'f JrM3 W C�iU S-Z Z41
Signature of a tfied Well Contractor Date
6.Is(are)the well(s)JPermanent or Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or lallo 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:
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
9.Total well depth below land surface: I V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3 0 (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) II Method of test: air 24c.For Water Supply&Infection 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: C completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016