GW1--04009_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:P )`- ' �{`
3o\nn Li) �C, .1�! VV 0 1�v- 14.':WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
ii-US5A i56 it isi ft. Za I.-,
ft. ft.
NC Well Contractor Certification Number 515/.OUTER CASING(for iniul ii`ed well.�);ORTLr ER'(if i"'licablep ,,'.;,:.=:
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft• 56 ft- 61/8 in' SDR21 PVC
Company Name ,16 INNER CASING.OR TUBING" eothermiil clo"eed=loo
(B P)
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.
ft'
3.Well Use(check well use): •
in.
.;17:SCREENi :::?. -•.: ...,<:a'L-:.''' awe14:4..:i.;t•;•.yt?`' y ; t:^,`.•. ': .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑MunicipalfPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ' ft ft. in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) :18i.GROUT:.... ; :- -"'•'-,-;. ;,b-t- ':-<;:,::• :._4,c ;;
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL _ 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
—
:l.19::SAND/GRAVEL'PACK(if applicable) --
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer I20:DRILLING LOG(attliaildditionalilieeb`ifiieFisiti p):,;=.` .-_•-:::_•-`- ::<'';
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type grain size etc.)
® ft. Zg ft- mod- )--ir-1'
4.Date Well(s)Completed: Well ID# (2 9 ft' 2- ft. igrat,,✓) 12.d(
/
5a.Well Location: ! 3 ft. 1SS ft G G h,„�lt
60 4—M sN4'As ft. ft. • .,. , •. .•
-Facility/Owner Name Facility ID#(if applicable)
f. ft 1 "LI.�L: ,� 1...
2tsi7-3o27 Nc-21 Ail Cikeic(1- Al ft' f_ JUL 01 8 2024
Physical Address,City,and Zip ft. ft.
,zr Jrd
21 REMARKS ',`.-,,14,.,,,..r..... .,.:,,.--, ..
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:
3s 314/7/13 N —7 y . q 7g' /qgZ W (-2s-2_
6.Is(are)the well(s): l lPermanent 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 ItNo 15A NCAC 02C.0100 or 1SA 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: I 24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: J o (ft)
For multiple wells list all depths if different(example-3(a3200'and 2 a@100) Submit this GW-1 within 30 days of well completion per the following:
So 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) 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
(ie.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
2 air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018