GW1--07634_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
•
1.Well Contractor Information: •
3 C( 1/ 1 7dd T ) 14:'WATERZONES `.:::. '':..: _ .
FROM TO DESCRIPTION
Well Contractor Name'
ft. ft.
CiS'S ft. ft. I.
NC Well Contractor Certification Number . AS:" CASING'(fii•.multi:caged:wella)'ORRLINER(if ap'licable):-.•z• :'•-
- Morgan Well I I & Pump,m , INCFROM TO DIAMETER. , THICKNESS MATERIAL
p 1 it 61 6 ft. 6 1/8 in•• SDR21 PVC
Company Name •i )/ , 1� 16.1NNER'CASING"OR TIIBING'(geothermal'closed=loop):.:.`. - , -
2.Well Construction Permit#: (A/C.. a �23'Zk�-`, FROM TO DIAMETER: THICKNESS MATERL4L ,
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.
1.17:.SCREEN' °,C':''.--':?: '- `"..,. • -.••'.-4:•:';•,..• .
Water Supply Well:
FROM , TO DIAMETER • SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in. •
OGeothermal(Heating/Cooling Supply) iesidential Water Supply(single) ft. ft. in. '
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
•19:SAND/GRAVEL PACK(if applicable)... .. .- ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM , TO MATERIAL • EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer ..20:DRILLING.LOG(attibli bdditidna1.slieets if ne`cesliiry) 'L•:st :'s•: :•::"2::..."'".-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cola,hard ess,sail/rock type grain size,etc.)
y to ft. 1.0 ft. a rd �lr
4.Date Wells)Completed: it" ell ID# (�V� f 5 f F t�it{�//lU�,P rq' .
5a.Well Location: �� t. ('JJ z H. �l is
5irtily + Aj 1 9 I ft. ` i�/�[ft. el raft v,..I-..e
Facility/OwnerNa&e Facility (if ap licable)
j y
Physical Add/rests,City,and Zip ft. ft. ��y (�
1-or 1/176a '21..REMARK.T. . • ... -. .''.-1... :P.Cr-.'."`.�.:L023..,. . -..., ..
County Parcel Identification No.(PIN) Info E1r-2 Pr-...,,-.,..:_
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
35- L) QYN PZJ ZT3053 W l 04..1 jk-23
6.Is(are)the well(s): InPermanent or OTemporary Signature of rti e e I Contractor Date.
By signing this form,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !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: I�� (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)
10.Static water level below top of casing: ® (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter 6 (in) Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: rotary•1ry 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
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) C•/ Method of test:
4' L° t,-
granulated chlorine
13b.Disinfection type: Amount:
Bonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018