GW1--01567_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J^1/ toddy 14.WATER ZONES
Well Conhaleg fety{orName
� FROM TO DESCRIPTION
s '^4n ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
M o rg a n Well & Pump, I N C • FROM TO DIAMETER THICKNESS MATERIAL
0 ft. [.)14 ft• 61/8 in• sdr-21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal-closed-loop)...
2.Well Construction Permit#: 370 FROM TO DL4METER THICKNESS MATERIAL
List all applicable well construction permit (i.e.UI , ounty,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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) .residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial '❑Residential Water Supply(shared) 18.:GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft. '
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ' ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El (explain under#21 Remarks) FROM TO DESCRIPTION(color,haarrddness,soil/rock type,grain size,etc.)
4.Date Wells)Completed: i-a-L.4 Well ID# 2Z ft. Cam/ ft. 8
5a.Well Location: 3 U ft. gig ft. nut
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tp ,,,,,;--.1.,,_ ,, .-
I�1 t& '[Q/ e�lkrG� ft. C�� ft. r r Ls.�...i ,:
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR 0. 8 2n,4,
Goo 11 I� t'(�i s� .G� ft. ft. :nyc:. �:: 1 ;� . .. t
Physical Address,City,and Zip ft. ft. + ""' u V��>
C1O ;"1f.
21.REMARKS. -
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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.Certification:
Jc.� % N To. C$V`6�i w 1-3/-2 4/
Signature o ertified Well Contractor Date
6.Is(are)the well(s): llPermanent or OTemporary
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' , 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: "f J (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@a 20 and 2@I00')
10.Static water level below top of casing: 3"D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter 6 1/8 (in•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Jo Method of test: air�
Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine "//, O�
13b.Disinfection type: Amount: 1 U
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018