GW1--04007_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
P
J O 1 '1 ' L �4/ -b V.)(lie-ti
FROM TO ATER ZONES DESCRIPTION
Well Contractor Name —quS5A !
Z ft. ,ZS ft L) Pj�
I ft. ft. J
NC Well Contractor Certification Number ;1.5:;O17TERTCASING(for'mniti-eifeed welh);ORLIlVER(lf:a licable)`b<_.,:: .'"
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft 57 ft. 6 1/8 in• SDR21 PVC
Company Name
.16:`INNER CASING.OR TUBING"(geothermal'clo`aed=lo'op): .. ='.Z.;.r?.'•`:.
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.
D' ft in.
Well Use(check well use):
1775CREEN:` :::•:'_'ai.%._ ._6.-.:; ,•'...s,..,..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industria]/Commercial ❑Residential Water Supply(shared) s18 GROUT::,".., . > : . . M:c - _ :<;?`-: _ _. .. .:_,.!..-
1 rrigation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 f• bentonite _poured
❑Monitoring ❑Recovery it ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
—
1:.19::SAND/GRAV.EAPACK'Of applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLINGLOG(attacliadditionslabesisiineeesiary)^ .=r=;:,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
O ft 26 ft. Kcal- jlY9-
4.Date Well(s)Completed: Well ID# 2 7 it' 1/ 7 ft. /3 jOW/1 reaa<
5a.Well Location: ys ft 1‘7 ft' 6=-4.) G t"'',,,,'i•
- -Facility/Owner Name Facility Facility ID#(if applicable) D ft `P .L. : „Y �� '`
2"<7-3oz7 Svc-it/ Mt ( ;/&)- "tic ft ft. JUL 0 8 2024
Physical Address,City,and Zip ft ft.
xr-; W._.- II !''.-.aryc. I43r.
-21FREMARKS`:'d`. 'rid V +.:{{ ::_:. r 9.-;' s
'I°4 0..1 LNG t>ii'..43G�
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:
35. 3M7//3 N -79. 978'‘ 93'2 W4;e1/46 -2S Zy
Is(are)the well(s): LlPermanent or ❑Tern or Si e of Certified Well Contractor Date
6. P az'Y
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I No 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: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /g S (ft)
For multiple wells list all depths if different(example-3@Z00'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: SD (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) 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
/ air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018