GW1--06485_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor Information: - •
OYlfl LUI lLP vii7 V\1( I( :'.
'•14.,WATERZONES v..4.1".'--.? �.C•.'. .
Well Contractor Name FROM TO _ DESCRIPTION I
IQS 3,A
Z • 241 ftG 9pr\ I '
ft. ft. I
NC Well Contractor Certification Number 1:15i OliiE.W.CA EIG'(frii•multi-caeed,wells):ORUJINER Cif.W1icible)•;%:: ''
Morgan Well & Pump, INC FROM TO DIAMETER , THICKNESS MATERIAL _
1 ft• 65 ft 61/8 SDR21 PVC
Company Name
�ot of tI G 6 6 •16:INNER CASING.OR TUBING(ge'otherraiil closed loop) -:^x .:.. _
2.Well Construction Permit#: 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: is17cSCREEN '-'':•'_ -.--'•'; .:. :-.ri •:.r2'r_::-.;;:.e:'; • r:'.:"::':'•. • •
FROM TO DIAMETER SLOT SIZE _ THICKNESS ' MATERIAL
❑Agricultural . ❑M��unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft. in. '
❑Industrial/Commercial DResidential Water Supply(shared) ll18:;GRODT.:::!.; _ . .:t':•;;7,. 1,•.•..--7•;: •.; . .',;:
❑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. f.
❑Aquifer Recharge ❑Groundwater Remediation
119.:SANDLGRAV.EL`PACK'(tfspplicable)'i '" - : s-t:•_� .,;^.:•.,:.-;.•:4. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. .
❑Experimental Technology 0 Subsidence Control ft. ft.
_ ❑Geothermal(Closed Loop) ❑Tracer :20:DRII,LINGLOG(attach addiiionill aheeta if rieCeeasaiy)2;'r... t '-.N.A.:':'; t I,•rt •
❑Geothermal(Heating/CoolingRetum) ❑Other(explainunder#21Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
0 ft. /8 ft. ge.d- ik-t-
' 4.Date Well(s)Completed: l o��-?�� Well ID# • III ft. 60 ft. 6,, , 64,...„ 4
5a.Well Location: ft ft
` dV()►_i le ha/116S II6 ft. ft. - V 6:..•,,i.•sa,Co'!i.... `+i� i1.:, .
Facility/OwnerName Facility lD#(if applicable) ft ft. NOV 0 4 20
Physieal Address,City,and Zip t-6 24
1d©2-5 sd✓k ii,,,A on bh C11q,r-jo s
l ft. ft IG`. :••, •- l - S"'
,Mtai•nbury 1:21:RRMARKS . `kip,, .;-.. . .. . . ..,...• ...Qa+(4':`'3fa .. ,
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: •
35 V 7 i5'sl N —go, 6i d63 W • �, 10-)7-Eh/
S• tun of erti ed We Contractor Date
6.Is(are)the well(s): nPermanent or ❑Temporary •
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IlNo 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:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft)
For multiple wells list all depths if different(example-3@200'and 2(3a 100) Submit this GW-1 within 30 days of well completion per the following:
j:
24a. For All Wells: Original form.to Division of Water Resources (DWR),
10.Static water level below top of casing: o (ft) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
Ifwater level is above casing;use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
{ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ro`a'►7 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 1100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 2I 699-1611
13b.Disinfection type:granulated chlorine Amount: 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018