GW1--05403_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
��11CII Contractor Information:
P )`- 1 /
Vv)fl W1 Ye, 1-'�! VV O 1CY 14.:WATER ZONES - .. . _
FROM TO DESCRIPTION
Well Contractor Name 0' ft 'v ft
2 f'
IQcJ JA 3y£� ft 3q i ft. 79`�x
NC Well Contractor Certification Number '15.OUTER CASING(for Multi-cased wells)ORLINER(if ap'licable)'
Morgan Well & Pump, INC^'V C FROM TO DIAMETER THICKNESS MATERIAL
1 ft- 65 ft 61/8 in. SDR21 PVC
Company Name
f n/J /� 16.:INNER CASING OR TUBING(gaothermil eldied loop)
2.Well Construction Permit#: +�V`I D 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 Well: -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�MMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) G'1Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ['Residential Water Supply(shared) 18:;GROUT
['Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 D' 20 ft. bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: —
DAquifer Recharge CI Groundwater Remediation
19.SAND/GRAVEL PACK(iif applicable):
❑Aquifer Storage and Recovery ❑SalinityBairier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft• R' _
❑Experimental Technology ❑Subsidence Control ft• ft.
['Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional bheeta if necessary).:. • " ::: ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(c1olor,hardness soil/rock type,grain size,etc.)
O ft /''8' ft key ,L. 1
4.Date Well(s)Completed: t _/Li Well ID# /9 ft 5 6' ft. jr/3As, RcieK
5a.Well Location: S7 ft 3 6'd ft 6ss y 6 p i1 i e
ft ft.
ied6 .vela Crr15i %-1 t ^ '�•
Facility/Owner Name Facility ID#(if applicable) ft ft. ,` ./L.'L.
g137 S7iK65 Fel Vol- _c,,1661 /vC ft. ft SE P d 5 2024
Physical Address,City,and Zip )/ ft ft
��n1 st/ 21 RF.MARKR., �'. C.
i iiT:-
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:
3 5. 57ggqq ' N —go, 331 S q6 Z W 6-1'(-z
6.Is(are)the well(s): [Permanent or ['TemporarySigna a 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 [No ISA 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 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 366 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2(4)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tic (ft) 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
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: a i r 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