GW1--07631_Well Construction - GW1_20231204

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
v71j� •14i WATER ZONES:'. ::`: _•:'•• _::+..: "!...: r.:. ' "..::.. • •:.
't' FROM TO _ DESCRIPTION - - .
Well Contractor Name ft. ft
'T'c.-7C 9`--7,1 ft. ft. '
NC Well Contractor Certification Number :.15:OUTER CASING.(for iaiilti=cage"d:welle).OR.LTNER(if ap livable):-'.:;. .'•, . .
Moran Well & P u n , INCFROM TO DIAMETER THICKNESS MATERIAL
gp 1 ft. ,� ft• 61/8 • SDR21 PVC
CompanyCompany Name
L 0� � Z ��()�� .16.11VNEltCASING'OR•••TIIBING�(gedtlicrmal'e161ei1=1oo �p)� :�::r::;:;i;"•'�" "' . .
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2.Well Construction Permit#: 1 v f//�J 0 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l e.UIC,County,State,Variance,etc.) ft. . ft. in.
3.Well Use(check well use): ft. ft. in.
;17:.SCREEN: ....- -V:<:•I'•:¢=:•; ..s".:_'.:r:::'_' `si. '::,., 4; :
.�.:' . := •
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS . MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) icResidential Water Supply(single) ft. 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
°19:SAND/GRAVEL'PACK(if ipplicable).. -. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
oOeothennal(Closed Loop) OTracer ::20:DRILIONGLOG'(attarliaddilidnal'stieetaiftieceaeary); ::4":? := ...`'-'="s:i
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillracktype grain size etc.)0
nVft. ,0 ft. /�,j .4.Date Well(s)Completed: t\1\S\f7'D Well ID# (vD ft. (45 ft. b�A(D�,/Qr 61
5a.Well Location: �� ft 4`I1 'ft WroVr` (bd.,
01'm 6� ,)/n ft. vs ft. I IAp; /I an i. _ tJ
Facility/Owner Name/ �i/p/ l Facility ID#(if applicable) C� II ft. ft.
l ly/(
6° t�.C.( r�I// /� 6) ft. ft. ;
ft ft .. 2—_-:.2—_-:.4 h ,,j: i 'a ' �1i
Physical Address,City,and Zip S'
`21.REMARK,V ", ::. �, ,'
G �h/ '�L•(: 0 =2023 ...
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4 t`'-1 "`•-•n r,°c :''.
(if well field,one lat/long is sufficient) 22.Certification: C'W I:`JjOi3
3 �64'4/12 N -SDI J/7 3(5 W 1 )�Zi•s�,3
e t ❑Ten or Signature Certi el Co ctor Date
6.Is(are)the well(s): nPerman n or p ary
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 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: ' 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')
/f 24a. For All Wells: Original foffi to Division of Water Resources (DWR),
10.Static water level below top of casing: L (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:p air pressure Permit Program,1611 MSC,Raleigh,'NC 27699-1611 •granulated chlorine
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018