GW1--04194_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 I
1.
Well ntContractor InfoInformation:on�:
\ VI V ' t!� i 14::WATERZONES .
v FROM TO DESCRIPTION µ ., y. ._- -"- - ....
Well Contractor Name
1 -^ 40 ft• ft.
aN rrib ft. /5"/ ft.
NC Well Contractor Certification Number
INCi:15i OUTEICCASING(fo%multi�as`e$welliTOR`LINER.(if`ap hcable)`; __ %-
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft' —1 1 ft. 6 1/8 i°' SDR21 PVC
Company Name V Y 0 1 ':., v
v IS `It' 10 =1G INNER`CASING;OR TQBING,(geottier'mal dosed loop) i
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.
ft.3.Well Use(check well use): ft. in.
Water Supply Well: �?`1177i SCREEN TOOM DIAMETER..X :SLOT SIZE TAMENESS MATERIAL
.L MATERIAL':'
DAgricultural ❑M cipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. ft. in.
❑IndustriallCommercial DResidential Water Supply(shared) 18aGROUr ' ~ ;. .:f . -=: _
❑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 appliccable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20:DRILlINGLOGi(attach sdditio`nal sheets if necessary) - .`__ :< _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc.)
1n II tt^^( 0 ft ( Oft 6�/UuW ` GO/1 / `
4.Date Well(s)Completed:W l4 W 1 a� Well ID# ter ft. ✓ -ft. ,/1 NCAy4�, . ],r ✓Y7 aii id �
5a.Well Location: 1 jo 2 g, W6 ft vil
1( Q�/C�/`r `tlkl� `t v':� �L�S1tya ` u olY K 7 ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
„^ _
/2 a) CR,14'fR4
i� @.
"' 'V ft. ft. ��, .s�..,,+'t.,..S P.S ).a.�w
Physical A d(reess,,City,and Zip ft ft. UT Q A .21n'23
��II LD 1.J,O y,Yn ` ::21t REMARKS::is '' • _ __,r..•
County Parcel Identification No.(PIN) lDry- -t...„:^'l Pr ,5 , .,g 1Jfik
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .33
22.Ce ''cation:
— 142t1C� 10 (3 N Sis1773C w af_ __
6.Is(are)the well(s): 1nPermanent or OTemporary Sign a of fled Well Con ct Date
By signing this form,I hereby certiify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l No ISA NCAC 02C.0100 or ISA 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
l�(
9.Total well depth below land surface: r f/ (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 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"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.) 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
13a.Yield(gpm) t 0 Method of test: pressure air Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine !1
13b.Disinfection type: Amount: 1 lv ii
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018