GW1--02892_Well Construction - GW1_20240510

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
) O'fln Lur \'e, h*7W( lr :,.: ; ' _;14:_WATERZONES ._,'I..::`�=':: .. •'. '..i::•.': :. •': .
Well Contractor Name n FROM TO •DESCRIPTION _
����•� 26o ft Z6 1 ft. 3 grin
1465 fr. i'66 ft. 7, p")
NC Well Contractor Certification Number 1;15OUT1',R:CASING(for'multi-cssed.ivells)'ORI;INER"(if.iji'livable)'!'::: '
Morgan Well & Pump, I N C FROM TO DIAMETER , THICKNESS MATERIAL.
Company Name 1 ft' 1.14 Jd ft. 6 1/8 in' SDR21 PVC
Z 04- /6S y 6 .46: NNER'CASING.ORTUBING'(Obtbermatelo`ied=loop)."s::`:=`,:&e.0 •2..
2.Well Construction Permit#: 7l FROM TO DIAMETER ' THICENESS 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.
417:SCREEN1:'`i:n:.:-_,If::� S:% '•_:.:'`. N:n as :.:^.'.= ='.i.-? '':,:� .".:: :
Water Supply Well: '3 =••
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural . ❑Municipal/Public ft. ft. in.
CI Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑In'igation ❑Wells>100,000 GPD FROM TO - ,-MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n' 20 ft• bentonite poured
:Monitoring DRecovery ft. ft.
Injection Well: •
ft ft.
DAquifer Recharge ❑Groundwater Remediation '_19rSAND/GRA'V.EL'.PACK'(iif applicable)::r"'•i'•: " :_ i:'-::-r ..
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer "r`20:1DRILLINGLOG(attachadaitionalaheeta`ifneceas`ary') *;':::4:c..:•:.=':::-'r=`•:'.
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilhock type grain size etc.)
U d ft. 3 6 ft. Rej-- j-+.rf
4.Date Well(s)Completed:%_Z6 Z Well lD# 3 7 ft .C3 ft. F31-d.//1 d-i'Y?
5a.WellLocation: Sfr y ft tog ft. 61,-04/4 S4.td-
J Arles T CoO/1.5 Jo 9 ft 1 z5 ft- 6� teocK
Facility/Owner Name p 1 Facility DV(if applicable) 1 ft. ft.
30 7 /'O'Iit..SeA l-�. , ca►-13 j/t 11C Ne ft. it
ft ft.
Physical Address,City, d Zip ;a .;,... 4 `'P. t 41 7„'.'„`
Si-e d- N y 6 3 g-63 --6611;;.21•REMARKS' .. -i:=w 1`-2: AT. . '"' r, : . ... . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
VA
(if well field,one lat/long issufficient)N _ GO. 9/s ee3 Z W 22.Certification: ,/`j t J J Ly-i r 1
"oil ni___ -,,, ,-,
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature of Certified Well 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 IJNo 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: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SOO (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1000
i
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: s0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
11.Borehole diameter 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1'636 MSC,Raleigh,NC 27699i. -1636
12.Well construction method: rotary 24c.For Water Supply and Open-Lo Jp 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) !
-y Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type:_ Amount:
Tirol,(:W-1 Nnrth Carolina llenart nent nfRnvirnnmental t)nality-llivicinn of Wafer Recn„re-c R-.,1c-,1 6_4_ont 52