GW1--07658_Well Construction - GW1_20231204

i
. I
Ii
WELL CONSTRUCTION RECORD (GW-1't For Internal Use Only: '
•
1.Well Contractor Information: •
Ja 9 ! c�. ' :.:: ' ' ' ... ..... . ..r.•... ... . . . .
.14:wATERzoNEs�:;�:.::- .: � .:,�1:~.�:�.':_;•:
FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
‘‘ dA ft. ft.
NC Well Contractor Certification Number :.157Ou'ri,R CASING:(fo$iiin111=611ed:welle)ORLINER(if ap licable)^. •.''. ;..• ••
Morgan
Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
p 1 ft. L?E ft. 61/8 '� SDR21 IPVC
Company Name . ,, 1 i n°1 4 •16.INNER CASINGORTUBING eotliermahcloeed=lo'o •_. .
2.Well Construction Permit#: �� �� L.7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Le.UIC,County,State,Variance,etc.) ft. • ft. in.
3.Well Use(check well use): ft- ft. m
17..SCREEN•.. . .. . ?' .:':-v.. . . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) )(Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) j 18:GROUD. •:.: ;>'•` :;:. :` ". .': '
❑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 applicable)::' .: .. '•.•` :--:'-‘1:i ;?.: : .
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer ;•20.DRILTINGLOG'(attabliadditioilifilieeteifne"tesdary)�•-..:•r=i^..ri:''' `i ".i-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
��]] 9 ® ft. ft. R a.`
^
4.Date Well(s)Completed: I I-I"1"121 Well ID# �®ft. ft. ®�i 1�.
5a.Well Location: Q S ft. /I o .ft, �yit
0nc5ttA•1 Cola Oel j'\tJ 90ft. nos ft. , 1c r l4"v
Facilit 4Owner Name Facility ID#(if applicable) ft. ft.
( 59 q l . l l l l'�"1 iLl ft. ft. '-
lll✓✓✓ v C= i^
Physical Address,City,and Zip fr. ft �" It,.K. is t�!a-." ?
21:R.EMA__RIC.5 C r _ _ _
County Parcel Identification No.(PIN) LJ�v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ? ' "''
' 4,S'i5��q
(if well field,one lat/long is sufficient) / �( 22.Cerrttificatio,:
ZS. c1.754#76 N of r (l/�zgo5 W _ I` ii1-2ar*t'5
6.Is(are)the well(s): nPermanent or ❑Temporary
Signature.f Certified WAR 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 I'JNo 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-Loo Geothermal Wells Navin 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.SUBMTTTAL 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(a,200'and 2@l00) i.
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: It) (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
24b.For Injection Wells:Copy to DWR,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(gpm) '° Method of test:
air pressure Permit Program,1611 MSC,Raleigh,/NC 27699-1611
X
granulated chlorine '. 60 2
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018