GW1--06023_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ;
\) o\ in LU e }-l*7`w( Y : , ` _.
..14..WATERZONES . ." 3',':'r .1,'... ,
Well Contractor Name FROM TO DESCRIPTION
LaS 5.A lzz ft , 1 z3 ft. Iz j,P�,
ft .
. ft. 1
NC Well Contractor Certification Number '15:OUTl.R CASING(for'i¢ulti=casedriiilli'ORT:INER(if.ap"livable).... , ~=.-..
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft• e c/ ft. 61/8 in- SDR21 PVC
CompanyCompany Name 16.•E!Il�R CASING:OR TUBING €othermnl closed loo
2.Well CoIlStruction Permit#: Z FROM TO DIAMETER THICANESS 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.
§;L7tSCREEN'-(:• -.' -'. :..,'. • ,' rz%isTfitt;:7' •:„z.:r" '.: .-: •::.-,:: .':a,.: ..- -
Water Supply Well: '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 1321 e/sidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential•Water Supply(shared) 1:18}:GROUT.;:;:i;' , - .. .::4 •— •.
❑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 ❑Groundwater Remediation
:19::SANDLGRAV.EL`EACKTifapplicable):'-• .' . :�•.:f:. .; .. _.,.,_.
❑Aquifer Storage and Recovery El Salinity Basler FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer :•420:DRILLtING LOG(attaefi additional-shied if rieceasai-y) :�`u :.'°-#'':: ."i. '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
/� /� ID 3 O ft Z 2—ft g�d1— 12i r)-
• 4.Date Well Qs)Completed: !�"7— Well # � ft' j t5 ft. 6,7 &nowt./
t.
5a.Well Location:tee PeinI ft f
e PeA 1-, te -, )'0-J1 .. ft. ft. •
Facility/Owns ame Facility ID#(if applicable) ft. ft ti ' '*,i 677 i^m, �.., 14.,.
6d_S' 4 y Pwfci- ti kI) S01/e04.)' IC ft. ft IOCT _ 2024
Physical Address,C`1{y and Zip ft ft
D44/116—7 d 1 t:21E REMARKS_... I:',`..... : 't : :, w 1'41 r... _.`
County Parcel ldentificationNo.(P)N). D/ •.,'2'-`-;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one le/long is sufficient) 22.Certification:
35; 6'5/5-17s N '''g6' , Z N /�� W 7---q-z9
S. tore of e ' ed Wel Contractor Date
6.Is(are)the well(s): InPermanent or ❑Temporary •
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 P1No 15A 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 remark 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.TotaI well depth below land surface: /`1�� (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 2Qa l00') i
/� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: e d (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in) Program,1636 MSC,Raleigh,NC 27699i.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
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I L�i� Method of test:
granulated chlorine ;
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018