GW1--05424_Well Construction - GW1_20240909

• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: `- 1 �/
O�fl �e. 1—i*7 V V i` .14...WATER ZONES . ..:•_:......:._';: -
FROM TO DESCRIPTION
Well Contractor NameikusA
•Z iiSft A ft 2S
ft.
NC Well Contractor Certification Number ;.15:OUTER:CASING(for innli=wedriielli):ORISSER(ff.a"liciible)s: :_. .
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
] �f� 1 ft. dZ ft 6 1/8 in' SDR21 PVC
Company Name Nl Cye/Ti 16 `: `'.`;
:IIQNER CASING.OR TUBING(geothermal doled-loop)
Well Construction Permit#: 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
Water Supply Well: FR TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural OMunicipal/Public// ft. ft. in.
OGeothermal(Heating/Cooling Supply) iitYResidential Water Supply(single) ft. ft. ' in,
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑lrrigation ❑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/GRAVEL PACK(f applicable)I• • :'t-s;<' ._
_. .....
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft' ft'
❑Experimental Technology 0 Subsidence Control ft• ft
❑Geothermal(Closed Loop) OTracer 20:DRILLING LCre(attaeli additional Aids if tieeesiiiiy)191.`r 1•`V' 'r ,.V
mal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geother
_ o ft 3g ft ge� iirt
4.Date Well(s)Completed: g 3 6 ell ID# 3 q ft 2.1vo ft 6k-7 G tit
ft. ft.
5a.Well Location:
)044 Alle l (b- ft. ft. ,---r
Facility/Owner Name Facility lD#(if applicable) ft. ft `'/C.'' %.i L
//ZZ7 e_or)) Spa4,75 hi' Gle►deilq-- NC ft ft SEP 9 9 2024
Physical Address,City,and Zip ft ft IfifO:l,-.F.i`s,. a.,..
t.011,4n J , >-.. ,. . .. ... r..7 , t pti,
7 3 2 cf3b S1:REMARKS: i; :_,'�
_,4JV
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:
35t 7Yz995Z N — 8 a 3 S3 W -.3°"'
6.Is(are)the well(s): nPermanent or OTemporary
S' ture o ' ed WelI 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: DYes or C1No I SA NCAC 02C.0100 or 1SA 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.
dulled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !g a (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@a 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (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
(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) 75 Method of test: air p re S S u re 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