GW1--06534_Well Construction - GW1_20241104

• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:i � `-
30"fln }. Ye 1-t i 7 V J r .. .•. .'.:�i_'. .. . '•` ..•'•14.,WA'r;ERZONES '��;.'
-
FROM TO DESCRIPTION !
Well ContractorName A
2i1 l ft Z11Z ft• q !qvLLJ g -
�9zft �193� I�p�'
NC Well Contractor CertificationNumber ;:15:OUTER:CASING'(frir iifulii•c ed,"y-ells�:ORI;INER(if.ap"licable)t: :_i:.
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS > ,
1 ft 3 Y ft 61/8 in• SDR21 PVC
CompanyName
G7//� 217 '.16:N ERCASING,ORTfD3)NG(geothermi�lclo's"ed-loop) c-:=iM1:..n.;
2.Well Construction Permit#: FROM TO DIAMETER THICK ESS MATERiAI,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. ill'
3.Well Use(check well we): • ft. ft in.
Water Supply Well: 'ii,175 SCREENI. ,:.",-. •. c•°i. :.•. tf.::;;g:..e-Et; • `::•:::-:.'• . •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑M��unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) l�ltesidential Water Supply(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1:18 GROUT.:•:i.;•:' _ .. .:k ::1;V;}t:.,•
❑Isigation - ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTNIETHOD&AMOUNT_
Non-Water Supply Well: 0 ft' 20 ft'. bentonite: poured
OMonitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .19•:SAND/.GRAVEL`PACK-(if ipplicable)'> '-•"- :{=,. 'i-,,•,;•';::;;r; ;;?, a:;a,f'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
-, ❑Geothezmal(Closed Loop) OTracer ZO.'DRILLINGLOB(attack iiil itional aheeta inieFeeiiiiy) -a;.`-:s?-:t T .
•
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,eta)
❑Geothermal(Heating/CoolingActual) • ❑Other(explain under#21 Remarks) 0 ft -1 v ft Pol II ,3 Fr/ y
L� y /-`
4.Date Well(s)Completed: /0—,G`Z /Well ID# 5 ft S ZC)ft• 6py 68f+44-ii
•
5a Well Location: ft ft V•,^T ' .
e ' ft. ft. ,
Facility/Owner Name FacffitylD#(if applicable) ft ft. NOV 0 �` 2024
1zlt� d/dt• � IZd 1"In` j�S JV C' ft. ft �.... • ?•• :: ..Ii,`J. Fd
' Physical Address,City,and Zip ft ft. [';`j,.�_ o;
1 t'm A _ :21:REIVIAR CR.'•_ v S i:..::':':. +r:.. . . .,..- .-.v.'-r+S•.€'.c':r'ii� .--''_'' ...-. ,
'I i
County , Parcel IdentificationNo.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/lon_ sufficient)is 22.Certification: •
35, 1s7a � N —00��°zs W f �� 10—/c Z9
S' tore of ' ed We Contractor
6.Is(are)the well(s): InPermanent or ❑Temporary
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 l JNo 15ANCAC 02C.0100 or Ill 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 ;'
r
9.Total well depth below land surface: (ft.) '
For multiple wells list all depths if different(example-3(a 00'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
i.(1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
6 24b.For Injection Wells:Co to D
11.Borehole diameter: (in.) pY ,Underground Injection Control(ILTC)
Program, MSC,Raleigh,NC 27699-1636
I.
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) 1 s Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 127699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018