GW1--00828_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Info-K-Fyorrmatio :'n
��v � n v 14 I t
.WATER ZONES I 1
Well Contractor Name FROM TO DESCRIPTION
ft. ft.�:J ft. ft. I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Morgan Well & Pump, I N C FROM TO DIAMETER, I THICKNESS MATERIAL
0 ft. JC ft. 6 1/8 'in• sdr-21 PVC
Company Name J` 16.INNER CASING OR TUBING(geothermal closed-loop) '
2.Well Construction Permit#: 3 33 lJ/ram FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ;in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) Residential yater Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD 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
DAquifer Test ❑Stormwater•Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothenal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRgrt TO� D cRIPT1oN(color,kalra�SoiUrock type,grain size,etc.)
.v( ft. /J ft. • Di.ten (_�f
4.Date Well(s)Completed: 11-z4'�-1 Well BO - ei10 ft. 70 ft To(r Jl/� axi
5a.Well Location:/.'' 1 70 ft. �J©s ft. j46 /' is/1I
l (� (, 11��=��J t�l (/ r/a s
ft. ft.tif lot
I Facility/Owner Name /j Facility ID#(if applicable) ft. ft ;^ :: k
the Fcbhir f(JJ/�'' ft. ft. I - ,... (; q
Physical Address,City,and Zip lJ j / ft. ft. tD J ZtJ�`t
Ll /pt/) 21.REMARKS t i,„-e.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one
`llaat/longisis�sufficient) 22.Certification:
SS. �e �I 5a N 1�• -cz ?L W (01 l^? -Z�
6.Is are the wells: I_IPermanent or ❑Tern ora Signature of Certified Well oo Date
Is(are) () P t'Y
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L!No 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 die 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: - OS (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(erampl @200'and 2@I00`)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �7 (ft.) Information Processing Unit,1617 MSC)Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
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) / Method of test: a j r Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
6 5-o
13b.Disinfection type: Amount: '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018