GW1--03373_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: —�
1.Well Contractor Information: •
?«1/ la ()' 14.WATER ZONES
WellCont ctorName FROM TO DESCRIPTION
Ci SS6 -4 ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. V ft. 6118 in• adr-21 PVC
�.Well ..-QII$Cruc11uu I'81.iHirM. -•.�.� #1 -=1,0- -u.Y..Li., 'WI..^•••s, ...Iraqi.. — _______--_
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: FROMN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural 0Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
QIndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
I',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring 0 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
••�
Aquifer Storage and Recovery 1 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
0Experimental Technology 0Subsidence Control ft. ft.
0Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color hardness,soil/rock type,grain size,etc.)
0Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ta ft ft. g(8 w" dt It
4.Date Well(s)Completed: -17- Well ID# 3 fa �r ft. z/1..e /I/r
5a.Well Location: t• . ft. h ft. /� lreUlw^ ( 53.c,
�3 ft v ft. U Q �t•�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
36 S 1/1,P111 27 Y-ciwc, ft. ft. ,� �-.1 /i U
Physical Address,City,and Zip ft. ft. °� /�•1 V ,"
1 IC91i 21.REMARKS JUA+ 1
0 4
County Parcel Identification No.(PIN) t`t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i•.,' •a•r •
(if well field,one lat/long is sufficient) 22.Certificatio : J!`
35,58116 . N l'(/7)a6 W ' ,7,-.)- 2 V
6.Is(are)the well(s)0Permanent or OTemporary Signature o Certified C tra r Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this u 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: (/6° (fL) 24a. For All Wells:t 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: ' i#
10.Static water level below top of casing: `O (ft.) Division of Water Resources,Informatids 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) 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
granulated chbrirurI13b.Disinfection type: g Amount: 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