GW1--07657_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
---- I
J4 /', _ 1e •14 WATER ZONES..: . .::.:_.�; .::•<.,:-?,.!' :•:.: .... 'i.- ,-. . • .
�,yJ t''v CJ FROM TO DESCRIPTION
Well Contract are ft. ft. 1
4 :5,(q---
ft. ft.
NC Well Contractor Certification Number ';16'-.OUTER CASING(for mnitifell eed:welle)ORLINER(If ap•Iiiable): .':..• .:
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft 56 ft 61/8 in. SDR21 PVC
Company Name
7 d��/� 16.INNElYCASING'ORTIIBING'•(geotlier`mal'closed-)oop)�:i`�•::?'�'� -.'=>:.":. .--`..'.•
2.Well Construction Permit#: /4/l FROM TO DIAMEI•ER THICKNESS MATERIAL
List all applicable well construction permits(i.e./IIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 117::SCREEN''::1 `<:•=,:••.?' .:. .r..; •=•.. :c- :a.:`-'..... :'.,•;:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
CI Geothermal(Heating/Cooling Supply) iesidential 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: O ft. 20 ft. bentonite poured
❑Monitoring • ❑Recovery ft. ft.
Injection Well: ft. ft.
. ❑Aquifer Recharge ❑Groundwater Remediation '
'.19:SAND/GRAVEL PACK(if applicable)....:: -c - .-
❑Aquifer Storage and Recovery 0 Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer • .20.DRU;I NGLOG'(attaclibdditionalihetaifnecessaiy) :..:',.;:':'=;c'.:-:-:'i=`!'i:r'-
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) ft 40 ft. r0�m / /y
4.Date Well(s)Completed: / /�1�—/3 Well ID# 0 ft. Sift. 5 O p `I oa` •
5a.Well Locatio : / ft V/' Z5 ft g l h e foirp-i-o
7)/
Facility/Owner Name 7�`/'//'1/^ n�,Facility ID#(if applicable) ft ft. , , , .-•; 'L:+ •{ /
7' /� (744 ')N Y 1A,l ft. ft. n 7 n
Physical Adass,City,and Zip ft ft. j J C !I L`,2
/ l_ ^ '21:REMARKS,', _ ': ..: ,. :; .. =.'t.
County Parcel Identification No.(PIN) ':,'.•",. 1'4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at11ong is sufficient) Y/ 22.Cerlif.tioII: •
, s .7$bi N`gl 3 V 71 Z) W .�//% /7-26-2,�
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well onttactor 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 I!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: LS (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) i
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ✓0 (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
- I '
12.Well construction method: rotary 24c.For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmenti of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
I air pressure Permit Program,1611 MSC,Raleigh)NC 27699-1611
13a.Yield(gpm) Method of test:
granulated chlorine 7.-9
J�/
13b.Disinfection type: Amount: .- o• 0 2-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018