GW1--04022_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
' 1.Well Contractor Informattion: ' • .
V r`'/ / Ti 14 Vf'i I RyLONES -c t'` , - Si 21 d..: : _.
Well Contractor Name FROM TO DESCRIPTION •
ft. ft
NC Well Contactor Certification Number 745 OUI'ER'CASING'jfarmulited`welti)O&'>I1vEA(if:a`"licatile)x ',y`.a ;``,•
Morgan Well & Pump, I N C FROM' TO DIAMETER THICKNESS MATERIAL
Company Name '1 ft' lOsiNZ, ft• 6 1/8 in• S.DR21 - _ PVC
/_ f/i/] . :16'IL�RER.0 GR VEINGraiiiitieimafiiiiiidlogp)R i.MT:-
2.Well Construction Permit#: V�/ L"1 01 )� FROM _ TO DIAMETER THICKNESS 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.
Water Supply W0II' Fil 40REEN;'P« s•'it;d'.�..`. 'Z:,Kt:'_v :ae „Zf . ;: ':;:#
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public - • ft, ft. in.
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❑Geothermal(Heating/Cooling Supply) 1`Residential Water Supply(single) ft ft. i in. .
❑lndustrial/Commercial ❑Residential Water Supply(shared) S G1tOUni,' ::.yv :aLs- t a ' :cs": ''. •ils
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft• bentonite poured
OMonitoring ❑Recovery it. ft. • '
Injection Well:
• ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation
19:'SAND/GRAVELtEACK(if i phcible)' . _
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage - ft. . ft.
❑Experimental Technology ❑Subsidence Control ft• ft.,
❑Geothermal(Closed Loop) OTracer 20 DRIITING- :OG'(atticti a`dditionfiGiitiee'te if n"eera',ary)iF f=`....
❑Geothermat(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO - DESCRIPTION(color,hardness,soii/rock type,grain size,etc.)
/ V ft- ?� � •(lid 4;r+
4.Date Well(s)Completed: ID�5 J�� Well ID# '0 ft• a ft- .9,co wiNoo1( -
5a.Well Location: �j •ft', 'J ft 1a.1C� t-t V .
N,Irk.' ���l5 7ft- clef" . it 54�'I-firovV /2cCit
Facility/Owner Name Facility 1D#(if applicable) ' G i� IL + 'ft. . �.1 RI n,i./)
44 Iltl� r
Physical Address,City,and Zip J ft. ft 4 }
(County Parcel Identification No.(MN) Ir ta:.:s.'F.1.i'r•'WI:71 :in
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ah t�t W
(if well field,one lat/long is sufficient) 22.Cer aeon: ••
3 . Z759 $1_/2)00 --W • c_ 1 ,-2,U
6.Is(are)the well(s): 11Permanent or ❑Temporary Signs of edified well Contractor Date
By signing this form,I hereby certafy,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 beenprovided to the well owner.
repair under#21 remarks sgction 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: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i � (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 0'and 2@100'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: 10 ( ) 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
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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 100,0.00 GPD:Copy to DWR,CCPCUA
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13a.Yield(gpm) J 6 Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:gr•anulated chlorine Amount: (0, 1 Is r) •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018