GW1--05415_Well Construction - GW1_20240909

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
• 1.Well Contractor Information:j � _ `-V 1
j O V) W t f Y-(, \1- 7 V a Icy 14:WATER ZONES .. .
Well Contractor Name
FROM - TO - DESCRIPTION
�
'i s A "2,4 ft. L1Zq ft. G t/ rq.I
ft. I ft.
NC Well Contractor Certification Number :115!O13TER:CASING(for multi-cased wellsy.OR INER'(if i""1Ickble): .:'.:,_.'=.'"
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 R gy ft. 61/8 in. SDR21 PVC
Company Name .15INNERCASING:ORT[IBING•(geotlibrmiitelo tr-16 p)::s;.' .,c;.: '':
2.Well Construction Permit#: WO 55 FROM TO DI4METER 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 m
e1.7isCREENi t:;t. __..:, "F 6.'.:.' =•`'"sr ;t;+V:-.X2::'-.. .:!;-:.• i.;F:;',i:••':, -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) %;- ,,,n- ,- .;,: ', --• _
'i18f,GROUT: ..e•;...n: _ �_.•�:'.._ _. . --_J -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft• bentonite poured
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ' ft.
❑Aquifer Recharge ❑Groundwater Remediation
39>SAND/GRAVET,'PACIC•Cif applicable)." . _- . .- .
❑Aquifer Storage and Recovery 0 Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft'
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer E'-i20:DRII.LINGLOG(attach d itionita'lieete'ifrieceaeary`) ':.jc=:_=`_::`'>._'
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Rem FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain she,etc.)
G/ O l S ft. /24- o3-I►+
e
4.Date Well(s)Completed: 0-13r 2 l Well ID# /6 f 75 ft' 8p-Av 1 S^A,1-- ____
5a.Well Location: /_,, e ft. 7/�y0 ft' 6i;n-y 6-Tit
RO 6 A/A4 . C 1.. C110n ft ft.
r
- -- -Facility/Owner Name Facility ID#(if applicable)
ft. ft i.� 1 * �.
q r s�k c Fe r1- &1 -ft' Jvc: Vin ft. ft. _ 014
ft ft. SEp
Physical Address,City,and Zip r
,SI/ //7 :..... ..;r _r: . `-
2024
21I2EMARKH9; r: t? ;;
County Parcel Identification No.(PIN) Q'i,''.11-:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. 57f goz6 N —go. 331 yl5 W '- /3 zlf
6.Is are the well(s): (!Permanent or ❑Temporary Sijifl )
f ed well Contractor Date
By signing this form Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l9No 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: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ti 7 (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@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Sd (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: rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
(ie.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) A 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