GW1--04839_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor11 ,`` Innfoor/ma�tio�n;:�q
CI )Il lvwr aek, • 14.WATERZONES.,.
Well Contractor`ra/to Name r FROM ' TO DESCRIPTION
,;J6 L Ci-J \ l��ft. 16� ft.
ft. ft.
NC Well Contractor Certification Number 15[OUTER CASING(flit miiltl-cased wells).ORLINER(if'AO licable)c, "=, • '
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 1 fr. i214 ft' 61/8 in. SDR21 PVC
Company Name
:16:MINER CASING OR TUBING'(geotliermal clo6ed-166p); t-,- -.1.. ., '
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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in. '
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial DResidential Water Supply(shared)
� �� '_18.'GROUTr: ''",•;r"'". ::.. .'.'�::":;:,'r':_ °,_�'.`;..'::,.:',-.-:', ,-,, ...-.
�3'rrigation ❑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.
DAquifer Recharge ❑Groundwater Remediation
:19:SAND/GRAVEL PACK(if applicable):••.:: .:.. . 4".."....":.i ... . ... • . .. .
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer ..20:DRILLING LOG'(attachadditioiial sheets if idecehsbs )', ,' :'::: .:. ..
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
��y� D ft. tit) ft' peel
1�
4.Date Well(s)Completed: 6'G0-27 Well ID# u(' ft. gSi OV ft. eats j. (
5ar\Well Location:
.yr- g!1 ff. /Og ft nl�� 5u`V� ��
1 �u1 3t�,l 1 e er log ft. ,�^„ ft. ain1f1,s.
Facsiliity/Owner Name I P (1 Facility lD#(if applicabl
e)
// `/7 ft. (�U ft.
c757 CA e`k S t l�1 • dfitc or L AK-- ft. ft.
Physical Address,City,and Zip ( ft. ft. 4-\L A� L)
'�,�,� 7 MS JUL 2,.,
CountyParcel Identification No.(PIN) 8 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ink'w^a 'U f i^: r,�J URA
(if well field,one lat/long is sufficient) 22.Certe44 _—•
v'Ys`t.l1nOG
'15,431 IS NCO:7 W7 /6.Is(are)the well(s): IlPermanent or ❑Temporary Signature Contractor Date
By signing this form,I hereby cerh,fy'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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: 000 (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')
3d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control()UC)
f�, Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r��. l 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) 5 Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: ��li
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018