GW1--04831_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
• 1.Well Contractor Information: -
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Well ContractorNa FROM TO • DESCRIPTION
• `k2 -- w5 & m ft- \° 511M
ft. ft.
NC Well Contractor Certification Number 15.,:OUTER:GASING:ifur.;mtiiti:6441 wells)ORLI?YER(if a)i licalije) ....
Morgan Well &Pump, INC L '`
Company Name
0 ft• ,,g R- 61/8 in* sdr-21 PVC
C �N 516.`�.,,,��,r,� . . .
T)INER: G.90....B1NG`.(giottieimalilosed-loop)'::' -.... ;:)'.: ;,: :::.:,
2.Well Construction Permit#: �%� FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Corot ,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: ITSGR73FN ems.•: ...:z,':: =;:<;.':';.':: .:: " :.1<.t
FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
•Agricultural OMunicipal/Public ft, ft, in.
•Geothermal(Heating/Cooling Supply) WIResidential Water Supply(single) ft ft. in.
I Industrial/Commercial I Residential Water Supply shared
_Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft- 20 ft- bentonite poured ,
•Monitoring EIRecovery ft. ft.
Injection Well:
ft. ft.
1 Aquifer Recharge 0 Groundwater Remediation
RAVEI,.'PACK(if applicable) .... .:•.Barrier 1!Aquifer Storage and Recovery 0 Sal inity Baer I9 SAND : TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test Q Stormwater Drainage fL fL
•Experimental Technology in Subsidence Control ft. ft.
*Geothermal(Closed Loop) [Tracer •20 DRILLiNG LOG(attach additional sheets If necessary) :;<:;:,.::::` ::::' ,':'
it Geothermal(Heating/Cooling Return) _1 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
V ft JD fL c.ed
.��1 fs
vt
• 4.Date Well(s)Completed:t7 ( 2. +Doi Well ID# ft ( t f j 0 VA-
5a.Well Location: ` ft' ft
�S �lt� by owvl 'C'a�Y Sa rd
� NeS• - 110 ft- fL 'btu- rl,i.i
Facility/Owner Name Facilitym#(if applicable) ft. ft •
-
ft ft. `-- - Itt
Physical Address,City, Zip ft. ft. L. ti ),�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t r `� 'a },..
(if well field,one lat/long is sufficient) 22.
22.Certification: G r r t, -�
3S .\on l N C7.J .5 n W 71)
6.Is(are)the wells)JPermanent or ]Temporary Si Certified Well Contractor Da e
B •gni this form,1 hereby ce t fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No w A 1SA NCAC 02C.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#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 nececcary.
drilled't SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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 r@200'and 2(a)100) construction to the following:
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 Infection 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) 6r(y 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: tZ 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