GW1--04740_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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' 1.Well Contractor Information: ` •
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Well Contractame FROM TO • DESCRIPTION
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NC Well Contractor Certification Number `15 00TEleCASING(foi'�multi4ia ed w7sj OR<LI1�iER(if.ap 1in61"e) ,;=:"(`i aft"'-`-a
Morgan Well & Pump, IN
anC FROM' T DIAMETER THICKNESS MATERIAL.
g .1 ft c l ft. 61/8 in* SDR21 PVC
Company Name •
w I CASINGOR-'UBING:(giotheimal'cloeed iiii .
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2.Well Construction Permit#: O Q v 6 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.
17TSGRREEN 4 ildUIV "• _ xt-.:s:� :.. .. . :." 7 , .,s1 •
Water Supply Well: FROM TO DIAMETER _ SLAT SIZE THICKNESS . MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) lygesidential Water Supply(single) ft ft. in. ' •
❑Industrial/Commercial ❑Residential Water Supply(shared) ti:(GROUT;:yt -`i'r,'Tw* , "`we " .`: ' ." ,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft• bentonite poured
DMonitoring ❑Recovery ft. ft.' -
Injection Well: ft.• ft. • -
❑Aquifer Recharge ❑Groundwater Remediation ,5 . . .. ili) 1": .; Air. - s.,i .
❑Aquifer Storage and Recovery ❑Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage • ft. ft.
❑Experimental Technology 0 Subsidence Control it ft.
❑Geothermal(Closed Loop) ❑Tracer 20DR11.113 iG3AG(`ettac'h<sdditionatidigtlifneauiryTeg.'{'es:'i 1;' ?=::
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO • DESCRIPTION(color,h tudneq wiurark type,grain du,etc.)
'.6/ � � 7 D ft. �roW'l d;��
4.Date Well(s)Completed: �� Well 1D# ft- �C7 Ci1g., ft. rkA/l\ l�pCi4
5a.Well Location: ft. I� T • .
' f�� ft ft.CGCoC, �CI ; �U,; LW'
Facility/Owner Name Facility ID#(if applicable) it ft. l- _; `
`rL°G tK1( Q,(Fv(A b ( ft ft. •''►'•c�- t+ L:.-}��,''
Physical Address,City,and Zip ft ft. A U G 1 2 2024
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21"RR7ITARKS..... _ T. a, --...; ..C: =.1
1; County Parcel Identification No.(PIN) C-I'i,,a 3C v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one mat/long is sufficient) 22.Certification: • .
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351.V©1P/ N •71,, 7 • W ff?:7'. 1-1/ -��3�tiII
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6.Is(are)the well(s): InPermanent or ❑Temporary
Signature ofCertified Well Contractor Date
By signing this form,'hereby certify.that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes .or InNo 1SA NCAC 02C.0100 or ISA 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. c
4. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells baying 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 Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: ' 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U� (R') Submit Hus GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 1(100)
ZS24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: (it) 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 (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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA •
13a.Yield(gpm) 7 Method of test air pressure Permit Program,1611MSC,Raleigh,NC27699-1611
gtanulated'chlorine -1
13b.Disinfection type: Amount: iG .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018