GW1--03462_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
✓1 1 T `�' 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
c/sc6-1R ft. ft.
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. . ft. 6 1!a in. stir-21 PVC
a, ,py Name
___1_= "' 1" ii r .d i , lkl l
....:. .. _..... _... ___ __ ._. _..... ..
L.W-ellC-;onstr.r„tron-P-e.m[t??.( 1T'l1ti/=L-7--`-�7 -w-_ _ _ _ _ ►:TI„- : /_ .__i .,,Is a,,: TfIIC11 9 _1uTt1R:_4
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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) JEO Residential Water Supply(single) ft. ft. in.
fIndustrial/Commercial [Residential Water Supply(shared) 18.GROUT
IlIrrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o R• 20 ft• bentonite poured
Monitoring 0Rccovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(lt applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test fStormwater Drainage ft.. ft.
®Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size etc.)
�+ d ft. IC. ft.
J�(SIIV dr-Ar
4.Date Well(s)Completed: c""r'I-L/(/ Well ID# ID ft. �/ 1 ft. ��c
5a.Well Location: 11 ft. 9S ft. Tato N
�' S ft. `)I ft. '6/AAif?. 1 t�
Facdi /O ner Name Facie ID# Ifs livable `^
[Tye Facility ( applicable) ft ft. l . , 4
ntlilhc/ sff;J)C . 1 ft. ft.
t; I-
.4Z4
Physical Address,City,and Zip [t ft 1
/ .1i _ 21.REMARKS ..,,, L*1-
CP County �/ Parcel Identification No.(PIN) i't
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onelaat/long is sufficient) / 22.Certifi .o 43s•snigl N �j . 47 3(S W of 9D-Z�
6.Is(are)the well(s)JPermanent or OTemporary Signs of Certified Well C tractor 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: QYes or No 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:
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.
dolled'' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: igi (ft) 24a. For All Wells: 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:
10.Static water level below top of casing: J (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) t....5- 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 the
C' 91- 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