GW1--03363_Well Construction - GW1_20240610

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CA) .7o c^�a -- 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor
[�G ft. ft
t�.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 _
-------'---_._.----.__ p ft. *P ft' I 6 1/8 in. I sdr-21 i PVC
r
--- ----- -- - _--.-- ------- - -- -- I In MN'V e.K i nnirvl.11K ;I,n , ;oearrer'naicne.t uuun
_ - ' FROM - '-70--._ .:-'..DLAIYIElER ' TH1l,tiN1:JJ 1V1A1Eicrnr. _ I-..__-.__
2.Well 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.
N
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Agricultural Municipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
0Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
ri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
f Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EDStormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Q Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach add[tional sheets if necessary)
- Other(explain under#21 Remarks FROM TO DESCRIPTION(color, artiness,soNrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ( p ) O ft. /JQ ft. Qp�a 1,f
•
4.Date Well(s)Completed: We11ID# `7b ft. S'10 ft. C„n,,m., /�■ju(c
p ft. , I ft. J,`f'f,,N /Lo
5a.► Well Location: n / �y
r41 c r a f oos 7' ft. Zoo ft. '�i c,fl1"`e
Facility/OwnerName Facility ID#(if applicable) ft ft. ..;,� w *�`;`j
31)(03 iY,\War\ ( - 6 ft. ft. F.;=v6:.I
Physical Address,City,and Zip ft. JUN 1 O �Z4
�•1 r\n oNr 21.REMARKS u
County l• Parcel Identification No.(PIN) h (R' e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laatt/llo7ngg is sufficient) 22.Cer' tin: .
S 5> ll k� N gl) .�D �
W S--01-t1�
6.Is(are)the well(s)JPermanent or ]I Temporary Signature o Certified We Contractor Date
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: aYes or jNo 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: 'Q'Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiljirent(example-3Q200'and 2®100) construction to the following:
10.Static water level below top of casing: '1SD (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 Iniection 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) 1_, 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
13b.Disinfection type: granulated chlorine Amount: (s ' t7 7 L 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