GW1--00836_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well`Contractor Information:
/1 o V 7966 c}fl 14.WATER ZONES I
Well Co\tf actor/Name 11"" FROM TO DESCRIPTION
q j A ft. ft. I I
C S6
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
• Morgan Well & Pump, .INC FROM TO DIAMETER THICKNESS MATERIAL
0 fr. ( � ft. 61/8 in sdr-21 PVC
Company Name I
2.Well Construction Permit#: ` �1
[)KO 1/' / - 16.INNER CASING OR TUBING(geothermal closed-loop)
L�Y) 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.
❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft. in.
❑lndustrial/Conrmercial DResidential Water Supply(shared) 18.GROUT
❑lnigation ❑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)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional'sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM O r DESCRIPTION(color,hardness,soil/rock type grain size etc.)
°(� ft. ft. grow✓/Nel t`
4.Date Well(s)Completed: ZY Well ID# ft. C ft. &r(/� G (
5a.Well Location: --,-1S ft. 5 ft. 11/llJ; __Ii.‘3-
14/I(l‘cdV+ /O11'411 ft. ft
Facility/Ownn/e�rNaamme ///J Facility ID#(if applicable) ft. ft. ti
C.35ya-t6 r 4d ft. ftft. ft. .)..� t.,.'8..�r: �r '4,-i,:.Physical Address,City,anip L' A
/V i 21.REMARKS i CD kl 5 2021 --
•County (1 Parcel Identification No.(PIN)
i7- :,; t�ir S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ln`�rr :
,)�
(if well field,one lat/long is sufficient).51736 N go. ci7 1 ik,1 w22.Cer I`` tion: ; •ta
35
r . I-ts--7.,ti
6.Is(are)the well(s): ['lPerrnanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cent(/that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t'JNo 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:I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 746c (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: kit') Information Processing Unit,1617 MSC,IRaleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR,'Underground Injection Control(IUC)
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
5,
13a.Yield(gpm) Method of test: air
j r
/
Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine J L °Z
13b.Disinfection type: Amount:
4 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018