GW1--03946_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C actor Information: -
.._14:WAtER$ONES'.:` . . . . .. . ... . ,
Well Contrac Arne FROM TO DESCRIPTION
• 34-k -- 7 ft 7� ft. I 0 rpri,
ft. / ft.
NC Well Contractor Certification Number .15.ODTER:.CASING;(for imitti-cased Willi)'OR LINER(if ap livable). ..
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL '
0 ft. /_3, ft 6 I/l in' sdr-21 PVC 1
Company Name C(Q
�_ 1 .:16.INNER: ' ING.OR:TUBING(geothermalclosed-loop):.: ,
2.Well Construction Permit#: ~l• FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,County,State, Variance,etc.) ft ft. in.
• 3.Well Use(check well use): ft ft In.
Water Supply Well: FROM
FR TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural 0Municipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft. In.
['Industrial/Commercial *Residential Water Supply(shared) 18 GROITC ..
('Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
['Monitoring ORecovery ft. ft.
Injection Well: _
ft. ft.
['Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) : 11..'fi L 7 ,
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT ME ht)D i
['Aquifer Test Ill Stormwater Drainage ft. ft J U 1 0
['Experimental Technology ['Subsidence Control ft. ft. 2024
irl r
Geothermal Closed LooTracer 20.DRILLINGLOG(siftaci additloualsheetsifneceanai' i.: .i"1 P�'`'"i
( [' FROM TO DESCRIPTION(color,hardness,son/roek i;itA�t't tc.)�`�';
['Geothermal(Heating/Cooling Return) __,Other(explain under#21 Remarks)
el ft.
I.
4.Date Well(s)Completed:41 ai Well ID# 10 ft r it ,„,,,CU�`Y ,.ff. ft .11 r
Sa Well Location: `�-.• roc.
tI S 55 ft.
Facnility wner N Facility ID#(if
�applicable)
��L� 55 ft S S ft btW,,� e c -
J G 6�` F
1 ft. ft. V�
ras_♦� �3
P ysica Address,City,and ip �j�'4 I ✓��Ay�� ft. ft
`L v 21.RFMARKC:, h-:. :t`w. ;.>? : ,:!
oun Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ' cation:
-S5. N _ _,39 S 1.4 w __/& .1-
6.Is are the wells _Permanent or ['TemporarySi o ertifie Well Contractor Dat
Is(are) ()
By ning t is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or jNo 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: ' 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 2Q100) construction to the following:
10.Static water level below top of casing: eaItl (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,mtary,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) to 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: 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