GW1--07664_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
•
1.Well Contractor Information: 1 •
Jppp / 14?WATER ZONES :.'r•::,.
�u :I TI
FROM TO DESCRIPTION
Well Contractor game ft. ft. + f
gS 5O m,i9 ft. ft.
NC Well Contractor Certification Number ':15 OUTER'CASING'(for iniilti=cssed:wells)OR:MBR(if a licable)''.: .• ',
Morgan Well & Pump,m , INCFROM TO DIAMETER THICKNESS MATERIAL
p 1 ft. ft. 61/8 in' SDR21 PVC
Company Name 16.INNER CASINGORTUBING eottiermal"dosed loo'
b it' ®'/ D .7 6 � (g P).:.:
2.Well Construction Permit#: FROM To/ DIAMErrx THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. aP 0 ft. tin.
ft. DD ft. •in•
3.Well Use(check well use):
le17:.SCREEN.. ,. .1:*'.. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) fAResidential Water Supply(single) ft. ft. in. '
❑Industrial/Commercial ❑Residential Water Supply(shared) 1:.18:GROlyE °"-_: :,:,'.r'•-- : '` =
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- bentonite poured
❑Monitoring ❑Recovery ft. ft. ,
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,19:SAND/GRAVEL-PACK df ipplidable)'.
❑Aquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer • •;20.DRILLTNGLOG(attachadditidniisfieetd ifneceildry);`;' ?i::i- : ?':•:.•:i
FROM TO DESCRIPTION(callo�r,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) n❑�Other(explainunder#21Remarks) H �f� ft / t-1
vo -:2A-m �/f (L�
4.Date Well(s)Completed: 9 Well ID# to
ft. ��y l''ft. (�f of�ft�
k(1.
5a.Well Location: .5 ft. c 9 ft. S1 b
11v
5ft. 0 ft. Cl rA n t '\
d G� u1 ft _. A
Facility/Owner Name Facility ID#(if applicable) ft. n
Dee .�ek c'o ft. ft. DEC ?023
Physical Address,City,and Zip ft. ft.
Li 1/7C >^ .-21:REMARKS;:. .• •_.. .. .. ."' -2,1' ` y`:�';: �?::jj'2i:
County . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certificatio
(3 -Z(t:ylaN `s /c /3 OW w 11 --Zv 2-3
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBNIITTAL INSTRUCTIONS
• 9.Total well depth below land surface: O (it) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths ft-different(example-3 0'and 2@100)
/l 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: .�`7'D (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (m•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota'•1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
/67 air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
granulated chlorine W • 'Le/
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018