GW1--04899_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW=1) For Internal Use Only:
1.Well Contractor Information: •
Olik:11;
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v\. 1.4f WATERZONES;i::'e=:::E'. „>;>.=::i` _(,•.:::=!• ::...-.. _. .-
FROM TO DESCRIPTION
Well Contractor Name �yqo ft e� l ft.
357Z- !+ �7
ft L ft
NC Well Contractor Certification Number 1.51 OUTER'CASING'(foc iiiuld4 iasedwells)°OR'LINER(if'ap'livable):!E.,.."':C .;
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft d© ft' 61/8 ' in' SDR21 PVC
Company Name
/_,, '16 INNERCASING_OR.TUBING:(geothermiil`clo6ed=loop)':' �"i.=`.7..
.':`.:':: .''''
2.Well Construction Permit#: A g6/24 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 4.7rSCREEN. . i,.r: :':',,: ' ,':' -
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18I;.GROUT.: .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 n• bentonite poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
P19:'SAND/GRAVEL-'PACK-,(if applicable)" ,,. ,.,-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal Closed Loo ❑Tracer 120 D1ULLINGLOG attichadditional"sheetsifnece`si r
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grata size etc.)
2Q ei ft. �d ft. ter_� /1 li t
4.Date Well(s)Completed: 4 1 2 Well ID# 4' ft. .5 ft. t
5a.Well Location:rr 53 n• 3� ft ail
/� _w eAto ft. ft J_
Facility/Owner Nc e- rrA,� /�, ✓J'r (Facility ID#(if applicable)
ft ft ...; e,o• j�o.»
/�5 Cc 4L.RC'UI Lf l ` Jal(5 �/�i ft. ft. L S.J�. i F L 1�1
r
•
Physical Address,City,and Zip ft fr i 9 .. 21123
eoweik, z I A-ngtiRF.MARKR
County Parcel Identification No.(PIN) • Iflt�ii7''�':c'1 i� '''- 4.:-.. ,..°F,Ur.
DWC'Oa
5b.-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C Ica' is
55-6 N$o1sZ I W 7-1
-43
6.Is(are)the well(s): nPermanent or ❑Temporary Signature Certified 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 ONo 1SANCAC 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: ..goo (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(�00'and 2@100') •
1 7 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"+" 1
6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)Borehole diameter ((in.)) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota't Y • 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: 244.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) M•ethod of test: a[r pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
type:
granulated chlorine • + -
13b.Disinfection e: . Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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