GW1--07663_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: •
Tal To clol —5-11> 14i WATERZONES i <_'s:;..• i...a•••... : "
FROM TO DESCRIPTION !
Well ContractorName ft. ft. I
(ISS (e ft. ft.
NC Well Contractor Certification Number i IT:OUTER CASING.`(for inirlti:cased:welli)"ORLINER(if aji'licable)^`. .: . . •
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft. gS ft. 61/8 'n• SDR21 PVC
Company Name � � � I vI q, lb;INNERCASING'ORTUBING- eotliermal"closeilloo ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. . ft. in.
ft.' ft. in
3.Well Use(check well use):
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Water Supply Well: ;"17.SCREEN :.-•:.::. s7. �':;.:1=, •. '.:::;::•: ..'.:;. :.
pp Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. ill
❑Industrial/Commercial Residential Water Supply(shared)
❑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/GRAYEIL PACK(if applicable)'.. a -• .-
oAquifer Storage and Recovery ❑SalinityBarrieI FROM - TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. i
❑Experimental Technology CI Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer :°20:DRILLINGLOG(attaelilidditional'slieeti it`neceSiary).:._ •: .`- ``i`•':
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FROM TO DESCRIPTION(color,hardness,so' rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft 6 ft. lig!{,r 14.Date Well(s)Completed: Well ID# ft ft. ft9 _ ()y 65a.WellLocafion: 1/0fty
7 -.ft. t,Vet/ 0 Tex ,. ei
77 Al'7,e/ Ree/ ft. ft. Its
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Ve5 (A V 14 3 1'"' 40fe cAtcl ft• ft
Physical Address,City,and Zip ft. ft.
C/ C0/1 21•REMARKS'`;:•,' .•_.. ... ?:,:. :0-:IY•'.0•./•;9. •1) .. • -'Y
' County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r'`''.2.:7:`.
(if well field,one lat/long is sufficient) 22•Ce •
Ss. 9”69-til N--7/. 0 73?.,/) . w
siy. -2___p_l___24 .
6.Is(are)the well(s): InPermanent or ❑Temporary Signature Certified W Co ctor Dat
By signing this form,I hereby cerhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I"1No 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: -3 7 S (ft)
For multiple wells list all depths if different(example-3@200'and 2Q100) Submit this GW 1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
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24b.For Injection Wells:Copy to DWR,Underground Injection Control(IiJC)
11.Borehole diameter: 6 (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
(i.e.auger,rotary,cable,duect push,etc.) county environmental health depart lent of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
o� airpressure Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Pc P1 Method of test:
granulated chlorine 1 5 a
13b.Disinfection type: Amount: a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018