GW1--07660_Well Construction - GW1_20231204

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /
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�(J� •14:WATERZONESf:•r:; :�:c`�.:-=ti::*::'.�: •f:.. •.:.-.:. • •••• ...�•:•• •:.:.-•i.-•.::.::
- FROM TO DESCRIPTION
Well Co/�,8 cto ame ft. ft.
/�✓G ft ft. i '
NC Well Contractor Certification Number A' _15:iOUTER CASING.(for multi cssed:welle)OR LINER(if ap'livable)5'.'.-
Morgan Well & Pump, I N C FROM TO DIAMETER :. THICKNESS MATERIAL
' 1 ft itt) ft. 61/8 in• SDR21 PVC
Company Name • -16:INNERCASING'ORTUBING• eotliermal"closed-lao '
L.
2.Well Construction Permit#: -' �^ J ® v t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. �-
ft. ft. in-
3.Well Use(check well use):
y�17::SCREEN .. ra ... .,.'s:..,. . ,t- ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural , ❑Municipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. M. . '
❑Tndustrial/Commercial • ❑Residential Water Supply(shared) is 18:.GROUT'•'`:.••• .- +• ::'.,•:.r:::::.-:I;- --.... . ..
❑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. it
DAquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL'PACK(if applicable)::.:'•.::.;.;='?i•: •-.:'.'):::.0.:";,,'.-:'-':--:. ,..
OAquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL• EMPLACEMENT METHOD
❑Aq uifer Test ❑Stormwater Drainage ft. ft. i
❑Experimental Technology 0 Subsidence Control ft. ft.
DGeothernial(Closed Loop) ❑Tracer ::20:DRILL:INGLOG"(attachaddittonar'slieetiifneceaeary)•.:'•„' ;.'.:i:•:i:'. •'::•:'
FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return)
q ❑Other(explain under#21 Remarks) 6� ft d ft.
t n E/J _)��r
• 4.Date Well(s)Completed:•-1-I V— i Well 1D# To ft. S ft. lot��(,,�^(/�ci I f+
5a.Well Location: 7 5 ft /!S *ft
AP /N le
pt-
fili6 M f.I U /J is ft. 3 2S ft. g I vie, V�J t.`44)
Facility/Owner Name Facility ID#(if applicable). ft. ft
ft. ft. r: 4
Physical Address,City,and Zip
21:RF.MARKA:r. . .... - ;':-:. ..;1 kf..:.):%'
County Parcel Identification No.(PIN) • is;:u„ Tl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: PO..` " '�'�
(if well field,one lat/long is sufficient) 22.Certification:
��: /64 N — Z,7cOtie 6 w —/ _� Z
/..-~ c 1,
6.Is(are)the well(s): OPermanent or DTemporary Signature of C. ..ed Well Contractor ! Date
• By signing this form,I hereby cert((5i 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 1SA 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: , (ft) ISubmit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(cramp e-3@200'aria 2@100)
3 ft 24a. For All Wells: Original form tb 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"+"
624b.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'1 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 51 Method of test:
air pressure Permit Program,1611 MSC,Raleigh;NC 27699-1611
granulated chlorine / Z, S aZ
13b.Disinfection type: Amount:
Form GW-1 .: North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018