GW1--03375_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
(I• \ —c% T , 14.WATER ZONES
�C FROM TO DESCRIPTION
Well Contractor Name
1 ft. ft.
- C
A ft ft
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells)OR LINER(if ap.licable)
Morgan Well&Pump, INC PROM To DIAMETER THICKNESS MATERIAL
0 ft % ft 6 t/6 in' sdr-21 PVC
2.Well Construction Permit#: — " 6 w� -- — em O —DIAMETER THICKN: — TERIA- --- - -_
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
©Agricultural 0Municipal/Public ft ft. in.
()Geothermal(Heating/Cooling Supply) '1 Residential Water Supply(single) ft ft. in.
()Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
I1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft• bentonite poured
Monitoring ()Recovery ft. ft.
Injection Well: ft ft.
()Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
()Aquifer Storage and Recovery ()Salinity Bather FROM To MATERIAL EMPLACEMENT METHOD
()Aquifer Test ()Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks)
1-4- (11'.
L Q I1 f. N ft gyp-1 d
4.Date Well(s)Completed: -f l V f' Well ID# ���VJft �j`D ft. �l�Er�Oc�n ca j ��
5a.Well Location: 'lip ft i j,C ft. 15(oldn IL/C1
l FA kr..ty_ AN e(SOr) ,S ft Yes " U fc,nt i'e,
Facility/Owner Name n Facility ID#(if applicable) ft ft.
ft
Physical Address,City,and Zipft t,'
t ,14CO 1/1 21.REMARKS J U N 1 0 4,1,1
County Parcel Identification No.(PIN) ��
ilaforR Q4 1 'i..-�,,,"{ -7
UpAt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onnelat/long is
�/1 sufficient) 22.Certifica on 1
3�/ /elS OD N `� . OLiI) f W S --t/—Z"D
6.Is(are)the well(s)JPermanent or ()Temporary Signature ce ' ed ell ontractor 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: ()Yes or EiNo with ISA 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:' QC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i O J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d�erent(example-3( 200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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) / J 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
13b.Disinfection type: granulated chlorine Amount: C •5 0 (7, 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