GW1--07659_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: •
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JOY 70a1171It 14:WATER ZONES.::: - :
FROM TO DESCRIPTION I
Well ContracrorNfte ft. ft.
(S.6—'4 ft. ft.
NC Well Contractor Certification Number ';15POUTERCASING.(forinnittfddied:wells):ORT.INER(ifa licabl'e) C..•`:'::; ..
Morgan Well & Pump,m , INCFROM TO DIAMETER THICKNESS MATERIAL
P 1 ft. CI - ft. 61/8 in. sDR21 PVC
Company Name 1 . ry �7 .16.INNER'CASING'OR•TUBING'.(airitlidlidil"cldsefl.lobp)= :::'�`-.,`-.` ' _.•
2.Well Construction Permit#: 6,MA ! .J—c)/�,(96 FROM TO : DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. . ft. Ui•
3.Well Use(check well use): ft ft in.
17:SCREEN ... - . .... -:t'. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) C kesidential Water Supply(single) ft. ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) ;.18:.GROUT .: :' . '-4':::•, :: ?`:; , ` ,11-.r;''.:`:••' .: :2: . - .
[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)...-•- : - .
:Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL . EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology CI Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer ..20:DRILUNG LOG(attar&additihnid-slieetaifnecess'ary):`..•:':r.=_:,::•:- '=-i: ::
FROM TO DESCRIPTIO
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) N co]or,hardness,soiVracktype grain size,etc.)
0 ft. 410 ft. 14.0 0111(4
4.Date Well(s)Completed: /I—7VZ1 Well ID# C I® ft. 1 ft. 8roWi Gi/ir .
5a.Well Location: 7 ypt. ft 7�' 0,row,,,, �a dt
lG/ � ft. ft.g14,-/ cc3 ��b ��Y6/�t 1�ii 0.4, 1 r
Facility/Owner Nark Facility ID#(if applicable) ,
6 Z0 � Z 9t LA
ft. ft. L :- Pr-
ft. ft.
Physical Address,
City,and .
>
�r 1�/� 21.RE.M/0E87;7::.•: _ =1l't:-�.'' -:441 J..'.` ..[ct:t.
County Parcel Identification No.(PIN) 4-1
tnior 7..211 :')'..:- -(.. •9 1-,i.i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v.' e::;` 3G
(if well field,one lat/long is sufficient) 22.Certification:
S • 47It N ft 33539 0 W ,, , gif\-1 p 1_)A C-z3
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature o •ed Well Contractor 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 INo 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SY° (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 forni to Division of Water Resources (DWR),
10.Static water level below top of casing: / (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater 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: rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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 pressureI Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type:granulated chlorine Amount: 4 • Z
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Form GW-1 • North Carolina Department of Environmental Quality-Division of Water Resources 1 i Revised 6-6-2018