GW1--03942_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
• 1.Well ctor Information:
___rst
14:i WATER ZONES . .,... x:..y.,,. ... ;'.:a:".:
Well Contractor a c
FROM TO SDESCRIPTION
ft. ft.
3v, /'\ tee yv S� r y
NC Well Contractor Certification Number 335 ft ft.
:15;:OUTER:CASINGIformulti4ase ells)'GRUNER(ifap licatile):'::'(;; -_:(:.g>:...
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft4 ft '61/8 in• sdr-21 PVC
Company Name
` 16.'INNE.ReCASING.ORTUBING:(geothermalcloaed400p)
2.Well Construction Permit#: \S 1 p3 FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.UIC,County,State, Variance,etc.) fL ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0Municipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) [$Residential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial OResidential Water Supply(shared) 18,GROUT
',Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: o fL 20 ft• bentonite poured
Monitoring 1 Recovery ft. ft. •
Injection Well:
Aquifer Recharge 0 Groundwater Remediation ft. ft
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
QExperimental Technology [Subsidence Control ft. ft.
DGeothermal(Closed Loop) DTracer .20:.DR1LEING.LOG(attael'additional sheets if necessary):
(Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
o ft. 10 ft. red cl irE
4.Date Well(s)Completed: 1(lZ 1.1.� Well ED# 1 b ft. ft. D ratan+ ``
(a r
5a.Well Location: at ft. a-5 ft. borttsjh ram..
ve., &eh}vxdi- a%5 ft. . it f e.v.3 st C n��e.
Facility/0 ner{NNaame 'GU
lD#(if applicable) \!
3SS � ,p K& \oYs�'(�C Zee-4ji.AL ft. ft. l l �/E .
� ft. ft
n....
Ph,,sical'A.dd`rreesss,,1►City,and Zip :,}.+ �y,.y ��cv 1{ r/�r /t'
Y1/�" CI \. `,1�1.04ARKS ... .w< . ...�G..f .�. 0. i 5 �0:2 f•'- .
County Parcel Identification No.(PIN) lr. A-.'.,' :'-,-. as;-.Ss lAti.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'A C1lLIte
•(if well field,one let/long is sufficient) 22.Certification:
.- S. Sig' N �. g35 W 6 /3
ar 6.Is(are)the wells) Permanent or Temporary Si:.••: .f ertifi ell Contractor DAte
By signing this form,I hereby ce;tjjfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or pallo 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.
drilled' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (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(4)100) construction to the following:
10.Static water level below top of casing: .SS (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
rotary above,also submit one copy of this form within 30 days of completion of well
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) 50 a 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: 3 OZ 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