GW1--04036_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor In ormation•
et
1-6Ae 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3kAf I ft. 'S60 ft. Iogrx7
ft. ft. (J{
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. R111 ft. 6 1/8 In. sdr-21 PVC
t_' A`.�M ; �D 16.INNER CASING OR TUBING(geothermal closed-loop) _
2.Well Construction Permit#: It`L`&'1 V d(:14.-V 9A-FROM 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(Agricultural OMunicipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) iiResidential Water Supply(single) ft. ft. in,
DlndustriauCommercial QResidential Water Supply(shared) 18.GROUT
-"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery 13 Salinity Barrier _FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
QExperimental Technology E3Subsidence Control ft. ft.
['Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
®Geothermal(Heating/Cooling`Return) Other(explain under#21 Remarks) C I5 1
4.Date Well(s)Completed(//7/? Well ID# V s7 f4 35 -61( N d
5a. go
Location: " ft. r� er
ft. _ )
� \`:VO\C,X`)�� ft. 90/ ft. �7tkOVN VI,Ci
Facility/Owner Name -'•,t `�Facciiliitty ID#(if applicable) �j ft. . ft 1, j
3� � � xvk \h+ `�.\ I�l ���0 ° ft. ft. `vim �� C ,-`L a;/ LJ
Physical Address,City,and Zip ft. ft.
a64.90k-S�oo�6 21.REMARKS
JUL 0 8 2024
County Parcel Identification No.(PIN) lr r6:1,s,,y;r 1 ►rr.', :;I' !J
lt
CrtiCalCii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ) 22.Ce ' ca'on:
55. N9, - W ��j/
6.Is(are)the well(s)0Permanent or OTemporary Signature erti d Well Contractor Dat
By sig this ,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No with 1SA NCAC 02C.0100 or 1SA 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.
`hued't SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 42-DD (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:
SC)10.Static water level below top of casing: (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 Inlection 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) 'D Method of test: air 24c.For Water Supply&Inlection 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: .4L 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