GW1--06044_Well Construction - GW1_20241011

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' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: - .
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30'nn L \Le 1--R*7w l ' _ ... .
'•14.,WATERZONES '� ".-.:� '}� ' '•°-
Well Contractor Name FROM TO DESCRIPTION i ?
lQS , IJS ft. 116 30 ttI I . _
NC Well Contractor CertificationNumber 0.5:•0DTER-CASING-(frif multi2aee0e110 ORLINER tin—livable)=;.•:
Morgan Well & Pump, I N C FROM TO DIAMETER 1 THICKNESS MATERIAL _
1 ft q5 ft 61/8 in. SDR21 JPVC
Company Name q y OlZ '.16:INNERCASING,ORTUBING eothermalilodaedldo
2.Well Construction Permit#: r/ FROM TO DrAMETER .THICRNEss MATERLAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.-Well Ilse(check well use): ft ft in.
Water Supply Well: 117i SCREEN:"' :.•-,, •. ' js.t.
-_,.,.._ :.•.rF i . --.,.r: - :' ',: > .••. : •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . DM��unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) CaIRResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑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.
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❑AquiferRechazge ❑Groundwater Remediation .;19.:SANDIGRAVEL`FACK'(ifapplirable)•: - : 4;" -; *;3r:;';: §-
❑Aquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
El Geothermal(Closed Loop) OTracer D0:DRILLING LOG(attach onal eheeta'if nece.iiry)'.ti is ^. --;! Y,r: •
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) FROM TO
DESCRIPTION(color,liarduesssowrocktypegrainsizeefe)
D it Z7 ft. Pe-d- Oki-
' 4.Date Well(s) q Completed: d`/f ZV Well ID# Z S. ft V.. f 8.'—w4 • wY
5faa. / 1.Well Location:�j� YS R' 16S f' d3i'Y y 6e-ill/ -
`�1 l Ut ---. r dPeAac-5 IC- ft ft. /� ti
Facility/Owner Name Facility ID#(if applicable) f ft 3!t b. `t.. = V )-- `�'
S L//6' At ••1.es---- p-.-_ cO,nc v)- A/C, 2-cdZS ft ft 0 i✓T ? I •/f 74
Physical Address,City,and Zip ft. ft.
i1.6 v5 •
I21:BFMAuucw•, ,..._._ : :<_ • '' ..'.',' :7 7%tZ<1•1=. r-;. -_` ' : ... ,
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,` one
lathing is sufficient) e/ { (� 22.Certification: '
,��, Y F`�/33 N 'b�, 7 7�� l t w q`')e� y
6.Is(are)the well(s): IJPermanent or - ❑Temporary•
S• tore of a ed Wel Contractor Date
By signing this form,Ihereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 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 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: /6' (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: `�° (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" i
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.BorehoIe diameter 6 (in)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: rotary.7 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) as Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount:
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•Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018