GW1--05402_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information: / 1 V
) O'flfl � It`P/ 1-I+?vJ f ,� 1 1 14.� MATER ZONES W�DESCRIP. _. .. .
TOWell Contractor Name
ii-uS5 436 ft- lip ft. syp/t/
ft. ft 1
NC Well Contractor Certification Number s.15.ODTER.CASING(for mitlti:caied/welLs)"ORLINER(iif ai'licable) I.:::
Morgan Well & Pump, I N C FROM TO DIAMETER- THICKNESS MATERIAL
1 ft• Sb ft. 61/8 in. SDR21 PVC
Company Name 16.-INNER CASING.OR TUBING eothermal closed-loo .. `
2.Well Construction Permit#: ✓ 33 b I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft rn•
3.Well Use(check well use): • ft ft_ in.
Water Supply Well: $;17;SCREEN rF
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural ❑MM/unicipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) [@Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ['Residential Water Supply(shared)
['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 0 Groundwater Remediation
'19:SAND/GRAVELPACK(if apphcabl) : `' ... :."-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test ❑StormwaterDrainage ft. R.
['Experimental Technology ❑Subsidence Control ft ft.
['Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach idditional sheets if neeeaiery) -".4 `59 'VT-::'a
FROM TO DESCRIPTION(color,hardness,sou/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) O ft i ft gG 1 or).
4.Date Well(s)Completed: O' Well ID# +i ft go ft 61.1 6v Kn.tjje
5a.Well Location: ft / ft j
i Pijp /LC ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
S75 � v' A)i' t LN 040r15d'l n/G ft ft. '.'" - .1 t-L
Phynsical Address,City,and Zip /' /7 ft ft SEP
p 9 2024
V.344/� Y \ z i 7// / IS.21:REMARKS. J.C.r 0
County Parcel Identification No.(PIN) it f:.:..,tr.i r 'a.', 4 U>
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35160�1 IS N. D 1-1310°l W g,-LI Z y
6.Is(are)the well(s): nPermanent or ['TemporaryS' lure of a ed We CII ontractor 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 PJNo 15A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a copy
If this it 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:
S.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: g t ° (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 aC200'and 2(41100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 50 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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: rota 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) 5 Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018