GW1--00268_Well Construction - GW1_20240105

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: .
.J✓t V 7..#.1 V'r 14:WATER ZONES.c.; := .: ;.'. .
Well Contractor Name FROM TO DESCRIPTION
ft ft
1-1k756-14 ft. ft.
NC Well Contractor Certification Number ;15:OUTER CASING.for h 1ti*iiitd.weUs ORi LINER _ . ..( ) (if a licablej"�r`r' •::
Morgan Well & Pump, I N C FROM DIAMETER THICKNESS MATERIAL
1 ITO
j(d ft- 61/8 in' SDR21 PVC
Company Name
/� ^-7O 16.INNER CASING OR TUBING(g'e6ttieimsl cloae'd=loop) :`.•.':i`',;` .... "..' .',• .
2.Well Construction Permit#: (6- v� r// FROM TO DIAMETER THICKNESS MATERIAL ,
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) ft. . ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ) Residential Water Supply(single) ft f in. —
❑Industrial/Commercial ❑Residential Water Supply(shared)
18:GROUT:' .. :.... ..,..,._ •., '.`.::`:7..:..
❑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 ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD —
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control ft ft
❑Geothermal(Closed Loop) OTracer 20.DRIId.3NG.LOG(attach additional ilieets iYuecessa"ry);',.`u: '.:: - -
FROM TO DESCRIPTION(co r,hardness,seiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling`Return) '►"�❑Other(explain under#21 Remarks) O `. r ^ i `l
4.Date Well(s)Completed: I-1 7-s•3 Well ED# B• 100 B• h O ( /�+`tt j
5a.Well Location: '�'0 ft. ( .ft 8 r71j,/ni/1,Q�i',�10-.
�Y 07 Nbene GI ft LO S ft p j u-c (Iran, 4 6
Facility/Owner Name Facility ID#(if applicable) R ft 'i
�,,/o/;�,Cd �� ft. f . `��-r f V L
Physical Address,City,n and Zip ft --� N 0 i (O24
�`�IIJ h ''2L REMARKS.°, _ .-. ,.- , ' -r."G' �' . {' :':; .. .is -s:i ..
IL
County Parcel Identification No.(PIN) DVVOis 9 UM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
55_`6i7r,Z N 1 7)2/7_ w I a-..7 i --a
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of ertified Well Contractor Date l(��
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 ItNo 1 5A 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: L 0 (ft) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(g200'and 2@100')
10.Static water level below top of casing: le (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Wellconstruction method: rotary 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) LO Method of test: pressure air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount: 1 .C 8
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018