GW1--04842_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C khs lbetaXt'
Well Contractor Name FROM TO DESCRIPTION
1 ft. r&& ft 1
cS /�7 Z J ft ft.
NC Well Contractor Certification Number '15.OUTER CASING(for mdlti=caied.weils)ORLINERCif ap licable)4r::;..... ...
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
earn an Name 1 ft• ft. 6 1/8 in. SDR21 PVC
P y 16 INNER CASING OR TUBING(geothermal closed loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalfPublic ft ft. in.
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `r
1117 i/gation ❑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 0 Groundwater Remediation
'.19:SAND/GRAVEL PACK•(rf applicable) :: _ -: ..
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control ft ft
❑Geothermal(Closed Loop) OTracer 120.DRILLING.LOG.(attach`additioiialaid-Mil if necessary) __ ,;_`.-
❑ Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grata size,etc.)
Geothermal(Heating/Cooling
Oft 3a ft 1 au)
4.Date Well(s)Completed: g•-(fYz3 Well ID# ,,1 ft. 60. ft. �ti
5a.Well Location: 6 I ft f ft. anvil ki
Dere-1(
Fac
ility/Owner Name Facility ID#(if applicable) ft.
� ft. ft !"` 4 .A.. ..;,f `Y
2 [`1 Oc°1�U edf) Rd, l !Y ft. ft. li'"`‘_ d 4...i V IZ
Physical Address,City,and Zip ft ft. J U[ 2, 8 2021
21:RF.MARKR'. •;,r:' - '--..`.•_=_-..;.: ... ;:_ -.,
County Parcel Identification No.(PIN) ifl�CiFrt :Dir Fri^-;;+u
i.:Zr°Q i.)ia
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.C `tifica on:
s ,ea 51 N 1O.74 ( b W 7 rz3
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
I
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 L'No 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: /'J7.7 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 3O (ft-) 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(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota'1 J�� 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) .7' Method of test:
a i r pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018