GW1--07644_Well Construction - GW1_20231204

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: •
()A y a —1-4 14 WATER'ZONES a_ _::S: ii`iil E:..... . ::. :.. . -C.._.-.._ . ..,.-3, _ , .
Well Contractor sine FROM TO DESCRIPTION
ft. ft.
c-*--fIT ft. ft.
NC Well Contractor Certification Number ',15 ODTER'.CASING.'(f i.iiiiiltifeiiiictwells)"OR:LINER'(ifap licable)"=r.:,j?s_a::-•,•_
Morgan Well & Pump, 'INC FROM TO _. .0 DIAMETER THICKNESS MATERIAL - '.,`.'
1 ft• , I' L 61/8 ; in' SDR21 PVC
Company Name ��/�� _16:INNER CA I'G_OItTLIBING"(geottiesiiial'bltised loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc) ft. . ft. in.
3.Well Use(check well use): ft ft in.
IE17.'SCREEN.:' �':`:"y,,;r=/'Z' ;i;':;:_'.:=`{ _ ?='," . c,7,7,::�' ._' . '; ;,
i:.,-_—_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in..
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) (.18:GROUT "
❑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/GRAVEN'PACK"(idappplieable)'.:'.::-•..:-,.:; ;„r-.-::3:r2= "--,-. ._ ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. .
❑Experimental Technology ❑Subsidence Control ft. ft. '
0 Geothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach:additionaliilletsifriecbsaary)1!Z.: :_:"-f=s-:':: -'.f -?;:'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soillrock type grain size,etc.)
0 ft. I ft. �a f
� 3 `' ^ .
4.Date Well(s)Completed: / '��l'7 Well ID# ft. ft. V AO VA ;
5a.Well Location: 15 ft. J i[ .ft �J1) 40� ^ D
I(/tC.,Y 1 C� to 11; f t / h ) f t (/ /4 o , 1C7 rc4f1
Facili /OwnerName l / Facility ID#(if applicable) ft ft, r
S.A/ tA'1/l d', , r.-1/ ft. ft. .7.�,-, w...<'r...m Ti a s '4..,.„„�..
Physical Address,City,and Zip ,, ft ft D`r 1� !• 7073
474.5.10i '.,2L;REMARKS.WY- 2-..,. s ,..:',Ii It J, 4;;. f _ ..:.
County Parcel Identification No.(PIN) 1>?"' "�y tJG,•t
t.is ma's_,i_,h2i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22 Certification:
3S. 3gDoz2.,N —Li''06U5?.gf W is i
6.Is(are)the well(s): InPermanent or ❑Temporary gna o Cetilled Well Con ctor Date
si ing t is form,I hereby certify t the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 1 CAC 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: U (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(41200'and 2@100)
3 V (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 '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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gp m) ' x Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine o
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018