GW1--03941_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
7
• 1.Well C r Info�rma ion:Vito
D de 1.1::WATER zoxFs . :i,.; ... .,. . .
Well Cont�c FROM TO DESCRIPTION
• 3 isz ft ts� " [0 Jr.,
ft ft
NC Well Contractor Certification Number :15:.OUTER.,CASING:(fdeisHilti-cased wells)ORLINER(if ap liable) ,
Morgan Well&Pump, INC • FROM TO DIAMETER THICKNESS MATERIAL
a ft D! ft 61/8 in' sdr-21 PVC
Company Name /
16.INNER:CASING.OR TUBING(geothermal closed-loop)`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.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
QAgricultural fMunicipal/Public ft ft. in.
Q Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single) ft ft, in.
fIndustrial/Commercial %Residential Water Supply(shared) • ,. •IS;GROUT.' ,`:'.. :. _, ..... . .:
i)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
—
Monitoring DRecovery ft. ft.
Injection Well: -
tt ft.
Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) .. .. ' "'
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stormwater Drainage ft ft
a Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DEILLINGLOG attack additional sheets if necesaary)
.. .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness,soil/rock type,gratn size eta)
ez ft k5 ft y� aq•,.6...
4.Date Well(s)Completed:(0//3f.L Well ID# `S ft ,'SS ft 6 faua r \tf"l"
Sa.Well Location: 35 ft. Cos ft -V (�r h oLt
I 1+t1- rrr�'
bSf t 4 b ftv
Fan'ity/OwnerNaame /� Facility ID#(if applicable) a ft �� t. �`-. * t / '
jli'LS ) Ci ^" tUL 1 ft ft. t.i 7 Iv L
1
28f ft. ft. JUL 0 e.2024 ....
P sical Address,City,and Zip
.�-�w+ . `�,�. h !�[� 21.RE)<�IARKS, i, x -:
County Parcel Identification No.(PIN) �'a',Q La j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. (3t4 N 43°. 4/3Filt W 22.7
6.Is(are)the well(s)EiPermanent or InTemporary Si x edified Well Contractor Date
By 'ni is form,I hereby certifil that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo with 15A NCAC 01C.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#11 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: --( S (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: 416 (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) ite) Method of test: air 24c.For Water Supply&Iniecton 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: 10 yZ 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