GW1--04898_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor FROM TO DESCRIPTION
557Z-A Leg ft. _I6b ft.
• ft. 1 ft.
NC Well Contractor Certification Number I>.15:OUTER'CASING(foi'.iiiiilti=caied:wells)ORLINER(ifap'livable). _.': ..,:,;;::a:'.
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. $Z ft• 61/8 in• SDR21 PVC
Company Name Ili .46i3NNER"CASING OR TUBING:(giethermal'dosed-ld'op)-..., :•_ ; s
2.Well Construction Permit#: 3 l`L d FROM TO DIAMETER THICKNESS ' MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft• . in.
3.Well Use(check well use): ft. ft. in
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) lidential Water Supply(single) n• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
ii19r SAND/GRAVEL'PACK(if.applieable),`a.c" - '=' .i'i''":s».':.- ""•,::•"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control ft. , ft. •
OGeothermal(Closed Loop) ❑Tracer 20:DRILLING LOG-(attic&additionaliiheeteifiieeeaiarp)•'_:.;i' :_:...-
FROM TO D CRIPTION(color,hardness,sai]/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft.�7 2D ft. ybr./�- 'id
4.Date Well(s)Completed: b / " Well ID# Z I ft. e a ft- / c _( t,�
•
5a.Well Locatioon:: Lk ft.
Zoo ft. c/l V&A1
(
-T�e., WG I t ft. ft.
Facility/Owner Name pp f D Facility ID#(if applicable) ft. ft.
4-0V$ SitfeM Me- F,1 v4 ft. ft. F''". 'y .'` A a^.'r'
Physical Address,City,and Zip ft. ft. rSya 14-,o i V C,1...)
si2L-.REMAA'RIZc. ..;': ,";:,.
Row`'u't D) I 1�� JUL v:... 2Q23
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lrfc"srwti^'n err"' ' Ur
(if well field,one lat/long is sufficient) pip �� 22.Certificatio N` 31�ta
(i^wQ ET N 017,55 6 W l t
—23
6.Is(are)the well(s): I:lPermanent or ❑Temporary Signature of Certifie e I 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 CJNo 15A NCAC 02C.0100 or 15,4 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
9.Total well depth below land surface: (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')
r� 24a. For All Wells: Original form to Division of Water Resources (DWR),
s 10.Static water level below top of casing: V - (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 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) j 2 Method of test:
a i r pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount: q Q';7
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018