GW1--00886_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 11
Jk dd gie® 14.WATER ZONES I i
Well Contractor ame FROM TO DESCRIPTION'
ft. ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if up licable)
Morgan Well & Pump, I N C FROM 0 DIAMETER' THICKNESS MATERIAL
0 ft. 4 ft. 61/8 in. sdr-21 PVC
Company Name
(,, 7�� 16.INNER CAS G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:C t g,1�4 z®i J / 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.
17.SCREEN
Water Supply Well:
FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) .esidential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑kigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft bentonite poured
DMonitoring ❑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.
DExperimental 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 TO DESCRIPTION(color,h rdness,soil/rock type,grain size etc.)
co ft. ft.
4.Date Well(s)Completed: /^/ 7LQ Well ID# 13ft. ij ft. [®pi\ fi c.i
ft. (J ft. P r `h j't
5a.Well Location: 1 77Vi1 n,1 0� 1 bit
l.t'�. �
-� ��ft. ft.
- 1�.- ..• ft. ft.
Facility/Owner Name Facility ID#(if applicable)
. 7 c- c ))ey '2 ft. ft. ;r� " .i T . • sI
,is 0a
PhysScal As,City,and Zip ft. ft. r n A
s,r�^ 21.REMARKS ! I-C D U U L V 2-r
County /�j` / (0` Parcel Identification No.(PIN) ","2 ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `rL�} '�
(if well field,one 1at/long is sufficient)
Q� r 22.Certif• •ti•J: nrJ 7
'�5 `d� f1't N DD �SV < W ���/ 17r. lv1i
Signature of`edified We Con 1 Date
6.Is(are)the well(s): CJPermanent or ❑Temporary g°
i
By signing this form,'hereby certi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or dNo 15A NCAC 02C.0100 or ISA 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:' r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface r J (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 ril100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
6 1/8 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 2709-1636
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: a j r
granulated chlorine I J 1 0'y
13b.Disinfection type: Amount: (r '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018