GW1--04741_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
. 1 1L.Contractor Information:
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Well Cont rName FROM TO DESCRIPTION
34"Itl-..-A /6 ft- ix( ft. 'IL gaiter
ft. ft. p75 1 J
NC Well Contractor Certification Number py,
:IS::OUTERCASING:.(for.;mntti=case. Wells)OR: INER(ff:ap livable) : ,..,
' Morgan Well&Pump, INC • • FROM To DIAMETER THICKNESS MATERIAL•
0 ft. as ft 61/8 in' sdr-21 PVC
Company Name
I 3 5)—" s16.`.RtER:CA�SING:OR TUBING'..(geothermal closed-loop)'::':.`:.,:..!:';:::......2: :''.. .i_
2.Well Construction Permit#: 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:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fAgriculttiral fMunicipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) NOResidential Water Supply(single) ft ft in. •
fllndustrial/Commercial •Residential Water Supply(shared) , ..
� IS:-GROUT.::'. .._.. ...;•;:...,. ,. `:. :. . , :.::,:: ::•
_!!Irrigation FROM TO MATERIAL :EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ftft-20 bentonite poured ;
Monitoring QRecovery ft. ft. .
Injection Well:
ft. ft.
0Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL'PACK(if applicable) •'
(Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ID Aquifer Test fl Stormwater Drainage ft t_.f
Experimental Technology ni Subsidence Control ft. ft.
Geothermal(Closed Loop) !Tracer 20:.1)RIPEINGLOti'attach--'additioiial'sheets"ffneces;a''
�'.Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sot/rock type,grain size etc.)
j 6 ft /D ft- bro►• a w t
4.Date Well(s)Completed: (J / /( /irii Well ID# rtt, ft. /5 ft. ,> A ' iraG
5a.Well Location: ,5 ft J? Q ft. etY �AW
ft ( ft. " ��.vv
111...
Facility/Owner Name Facility ID#(if applicable) ft ft ` } t
lJ6� t>✓ k— WWY► f1't,4l. L7ASTON N v& e, ft. ft 20
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Physical Address,City,and Zip `( ft ft AU 1 2 !-4
4:~4, , r; �
County Parcel Identification No.(PIN) I`C"1 t"'."'
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tification:
3S. .)4i5e{ N $4 0733 W 7L2 7 /A-(/
6.Is(are)the well(s)JPermanent or Temporary Signs e o citified Well Contractor Date
B onin is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or fj No with I5A 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: 31
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 2Q100) construction to the following:
10.Static water level below top of casing: 56 (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:
(ie.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) l C 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: /5 t Z. 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