GW1--04846_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contractor Information: ` '
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414:'',WATER7.ONES
FROM TO DESCRIPTION
Well Contractor N���� . •
+�i ft. ft.
ft.
NC Well Contractor Certification Number 71.5"OUTERGASINGI for inulitkitied we71.5)-OR LATER' a "livable. n 4.( ' ( "p ) lea
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft' 10 ft 61/8 in' SDR21 PVC
Company Name �� �.-6AENNER.CASINIG:ORSQBING'(geo'itieimal"rloee'd=7g4P)3NC•at `f..
2.Well Construction Permit#: s FROM TO DIAMETER THICKNESS ,MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use):, ft' ft. in
Water Su 1 Welli 't170SOREEN1rtio :;�,rs' .,e° sz -..,.'. A
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) 1Residential Water Supply(single) ft ft. in. '
❑Industrial/Commercial ❑Residential Water Supply(shared) p;18 GROUT, AMF:4 yr1, :`. ?.- r
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD do AMOUNT
Non-Water Supply Well: 0 ft 20 ft- bentonite poured
[]Monitoring ❑Recovery it. ft
Injection Well: .
ft ft
❑Aquifer Recharge ❑Groundwater Remediation r19.:SAND/GRAVELPACg:(ifiapPlicab1e) . ;a�:°'1"'l
❑Aquifer 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 20tDR]1flNG OG(attache`3ditionitlitieeti if he Cara 4);s=AVP..,.::_
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO ESCRIPTION(color,hardness solllrock type,grata size etc.)
ll -�, Well ID# •
0 1 S ft �IO • ain-
4.Date Well(s) �-
Completed: I� ft 5 c, ft 91't-8
is/. fl-
5a.Well Location: ft.. ft. 500 dA )11
0 .
trr1 t1(1ei p$ Ill Q ft- / ft f 6 .
Facility/Owner Name Facility lD#(if applicable) L 6 ft ft . /) (44/44
2�Z ) S/ °v1�n 041 ft ft 11�� r-- -
Physical Address,City,and Zip ft. ft . `w..s•. .1.. ' i/f
i 1LU)i .o21'-RFMARKs "'. _ - a /,{V i] jj 4.1
)n-::.--,:_�
1 L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .)a•!t
(if well field,one lat/long is sufficient) // ,, / 22.Certificatio DI,3S.SZ,1 N`1J I i (lit w 7.-/2-1,
6.Is(are)the well(s): L7Permanent or ❑Temporary Signature of edified 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 L'JNo 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 suction 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (7/ 'J (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@I00')
10.Static water level below top of'casing: 15 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
13a.Yield(gpm) '30 Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated'chlorine Amount: Z' I z 1 .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018