GW1--05430_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J O Yl n Luke -; 7 w-t- r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft pS 5 nn C 3Hv ft• 34/ ft. 13 1!PI
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft' l,/Z ft• 6 1/8 SDR21 PVC
Company Name
/(f� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 10I i 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MM�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [i�iResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R• OP N• poured
❑Monitoring ❑Recovery 0 ft. if 2- ft. PUMP 6HArt
Injection Well: J
ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O t� ge-I 1 Art
4.Date Well(s)Completed: O-� Z� Well ID# S 3(so GP;•- Gttk
ft. ft.
5a.Well Location: �" .. r ..
C4,�= love ft. t::_"�.•�:
Facility/Owner Name Facility ID#(if applicable) ft• ft
' S E P 0 9 2024 -
33ts/S 1P, jev kc)-- A/6e.►4,-/e NC- ft. ft.
Physical Address,City,and Zip ft. ft. U7S3
5 - - ' /3 7Z 7 6 21.REMARKS
County /M Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) L�C Sd 22.Certification:
S
, . //o7 (/iN -la J 7 / / W r --Zei
6.Is(are)the well(s): Permanent or ❑Temporary
S. lure o erti efi d Welf 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'1No 15A NCAC 02C.0100 or 1 SA 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 36O (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)
10.Static water level below of casing: 7 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use top
11.Borehole diameter: 6 On.) Program,
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) 13 Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018