GW1--03374_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
OV( t J� 14.WATER ZONES
Well Contract FROM TO DESCRIPTION
ft. ft.
r` ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cued wells)OR LINER(If ap.licable)
Mo
rgan organ Well & Pump, INC . FROM Ta DIAMETER THICKNESS MATERIAL
0 ft. ft. 61/8 in. sdr-21 PVC
. use ons uc.on 'erml `: I.i�7:Maaims -FRO-0- s -L,• --THIC-KPtESSff M#TERMI.-- ••
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.Water Supply Well: FROM SCREEN M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
0 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 40 ft• bentonite poured
OMonitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft.
Experimental Technology ()Subsidence Control ft. ft.
0Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks) 2 Q /`
/ 0 ft. 3 b ft ...a d ; l /,,
4.Date Well(s)Completed: J Z(/ "u Well ID# 30 ft. Se. ft. �"V^d f t�i
5a.Well Location: CO ft. 77 ft. rja1J^
d''/� S ��,' (/ 7 7 ft. 2�3 ft. !{ C-2 tAi '
>�1 /1C
Facility/Owner Nameme Facility ID#(if applicable) ft. ft. 'L ee .�..1 0 M 1. I: -
L_1
l S404 4J ft. ft.
� l
ft. ft. JUN I 0 2224
Physical Address,City,and Zip
21.REMARKS
1
n hak e'1 • - . 11eI!
County Parcel Identification No.(PIN) om
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(ifwell field,one lat/long is sufficient) q� 22.Certifc.ton:s
3.7.5 �y�t5 N l'i. V tJ w �i S-A
6.Is(are)the well(s)OPermanent or DTemporary Signature of Certified Well 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: Dyes or )No with 1SA 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:' 7 SUBMITTAL INSTRUCTIONS
L 9.Total well depth below land surface: °O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100') • construction to the following:
10.Static water level below top of casing: 9Q - - (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) .- Method of test: air 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
1 3b.Disinfection type: granulated chlorine Amount: 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