GW1--03322_Well Construction - GW1_20230512

I
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
I.Well Contractor Information:
C1'VV�S )'\OK�nOt✓t .14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name L ft
s� /� �Z7 . ft. I '
-A !i ft. ft.
NC Well Contractor Certification Number 15..OUTER'CASING for multi-eased.wells OR LINER a "livable
FROM TO DIAMETER THICKNESS MATERIAL
Morgan Well & Pump, I N C
1 ft- q ft. 61/8 to SDR21 JPVC
Company Name
p 16.INNER CASING OR TUBING eothecmal closed-loo
2.Well Construction Permit#: 4 SZ 3 FROM TO DIAMETER THICKNESS MA rFRTAT.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft in.
❑ludustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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.SAND/GRAVEL PACK(if a� livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional'sheets if necess
FROM To DESCRIPTION(color,hardness soillrocka size etc)
❑ m Geotheral(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
rr�� 72
ft 36 ft cd
4 4.Date Well(s)Completed: —111 4% Well ID# 3 ft 75 ft. ree,�l
ft ft.
5a.Well Location:
e ft. ft
Facili caner a Facility ID# rfa livable ft. ft
ty tY ( applicable)
ft.
LVLJ
J '1
Physical Address,Ci ,and Zip ft ft I +�
nn ��� �I� 21.REAIARKR
K
6Wvl a Irt'r*,t.r.�
County Parcel Identification No.(PIN) r �� ,-x3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lath ng is sufficient) 22.Ce •leatioII•
�1� N ��3z3
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Ce ied Well 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 LJNo 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 ofthis 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: ll S (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths:fdii ferent(example-3@200'and 2@100D
20 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is above casing,use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUQ
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
2, air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type:granulated chlorine Amount: de,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018