GW1--00272_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
� 7b� Jj� 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor a
ft. ft
455& --.11 ft. ft.
NC Well Contractor Certification Number 1S:OUTER CASING.for multi=cased:wells OR�LINER
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft. i.;$ ft' 6 1/8 SDR21 PVC
Company Name .16.INNER:CASING OR TUBING eottiermil closed 01i
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2.Well Construction Permit#: )3 / // FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable well construction permits 6,e.UIC,County,State,Variance,etc.) ft- . ft. ba.
3.Well Use(check well use): ft. ft' in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. it in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft. ft in.
❑Industrial/Commercial /Residential Water Supply(shared) 1.18:GROUT..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ti' bentonite poured
OMonitoring ❑Recovery ft. ft.
Injection Well:
f. f.
❑Aquifer Recharge ❑Groundwater Remediation :19:SAND/GRAVEL PACKOf inplicable).. .
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DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft.
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer • :.20.-DRILLING LOG(attacfi sdditionaisheets if necessity)...-':;:;'.'-`•>- "'._
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DE��SC/nRD?1TO/N�color, ardaess,soil/rocktype grain size,etc.)
Df. ?V ft aed i1 r a
4.Date Well(s)Completed: f 1s 1)Z3 Well ID# 70 f q� ft. b fax fr/ d i Pt
5a.Well Location:: //✓1/ IS ft I L ) ft. (4d(\ ILo a %
&5rc ki i-i /„-A Mks 1 (J aft ^/i 1... " y /Ys i, oair1 t&
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
ft. f.
70c3 (4/'M v"I/ G/t ft ft
Physical Address,City,and Zip
21.REMARKS
County Parcel Identifieti6n No.(PIN) I.. t• • p ��
' IL(-III iD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /�t�'
(if well field,one lat/long is
sufficient) 151,
J 1,. J G7 22.C ''c•'c(aa ti�on: J A N 0 2024
35-3/4/ N O /• Z// Z✓ w Intorralien?rn- LLil-Z S
6.Is(are)thewell(s): MPermanent or OTemporary
Signature.of Certified Well Contactor (.l� 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 laJNo 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 remark 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: 2 L✓ (ft) Submit this GW 1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3@200'and 2()a 100) y p g:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: C n (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water 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'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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 5 Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount: ! 2,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018