GW1--03911_Well Construction - GW1_20240705

PrintnTr :
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
1. Contrac tor ormation:
'OM :14 WA1ER:ZONES:.I> :..:.'.
Well Cont
on for Name FROM TO DESCRIPTION
� I I .6 " I13 " (Otee.,
NC Well Contractor Certification Number 15::OBTERGASIN :for:mnitti-cased.welli)'OR.T.117RR(if ap licable) ,.. .
Morgan Well &Pump, INC
FROM MATERIAL/TO DIAMETER THICKNESS
U ft !_5 ft '61/8 in• sdr-21 PVC
Compahy Name (�
C'� •16.INNER:CASINGOE:T11/ANG;(geottiecmaLclosEd-loop}:::.`.: ,::,'. .'..::.:';: :.:s; •
2.Well Construction Permit#: *bA `.r,C) PROM TO DIAMETER THICKNESS MATERIAL
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:
FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_Agricultural 0Municipal/Public .ft. ft. in.
Geothermal(Heating/Cooling Supply) mg Residential Water Supply(single) ft ft In. •
Industrial/Commercial OResidential Water Supply(shared) 0ROur ....: .. . :,:,:: -...,:: :..,:...
__ Irrigation Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft/ bentonite •d. C
)I Monitoring Recovery ft. ft � "a•'- ..V )
Injection Well: ft. •- I y E
0Aquifer Recharge 0 Groundwater Remediation
--!� 19.SAND/GRAVEL PACK(if applicable) ( .. •
0Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL A l METHOD
Aquifer Test Q Stormwater Drainage ft. ft fr :7:164:r. A.-,...
DExperimental Technology 0Subsidence Control ft ft 'A D 1't3)
DGeothermal(Closed Loop) tTracer 20:.RRIE aNGLOG(a'teach"s'ddittonalsheets Ifnecessa
Geothermal(Heating/Cooling Retu n) 0i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sotUrock type Brain size,etc.)
15 ft. Zb ft OA a_
4.Date Well(s)Completed:(0 I It 'I Well ID# ?s ft.
3S ft.
.$)y
5a.Well Location: {t w SCft. 5 Ycwr. �[ F ,h
I.. \kDi'j�Y10ty1 SO fr. AAIS ft' tut,
Facility/Owner Name Facility ID#(if applicable) ft. ft. �' 04
�
1) SA't 2E9 Sea kSt/t1 Yli 4( 28 Vic ft ft —
Physical Address,City,andZipppJJJ 5`t ` ft ft.
County Parcel Identification No.(PIN) . A . • . _ _ t. _., ,
I5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Nist.+s.4.-
(if well field,one lat/long is sufficient) 22. e ' cation:k35.Srl°I°l N 80.33a-a— W / i.tr/ 11
//6.Is(are)the well(s)JPermanent or �J Temporary Si e o rtified Well Contactor 1
By signing form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fl Yes or EjNo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constuction 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: ot6 (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 00•and 2@100') construction to the following:
10.Static water level below top of casing: d (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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)_ tp Method of test: air 24c.For Water Supply&Infection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: V 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