GW1--01337_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
1.Well Contractor Information:
! ''14.WATERZONES'' '
� J
Well Contractol-Name FROM TO DESCRIPTION
/I (C r ft. ft.
`' `j J �9 -A ft. ft.
NC Well Contractor Certification Number INC
15.OUTER CASING(for multi-cased'wells)OR LINER(if api licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
0 ft• )0I ft• 6 1/8 in. sdr-21 PVC
Company Name
{ ^/�1 16.INNER CASING OR'TUBING(geothermal closed-loop);,`
2.Well Construction Permit#: W ll- 1°J V" 5_t�l ��� 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.
1.7.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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 ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ''20.DRILLING LOG(attach additional sheets if necessary): . .,
TO DESCRtP ION(c
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FFROM (color,hardness,soil/rock type,grain size,etc.)
ft. US ft. ,jj� / d1#.
r
4.Date Well(s)Completed: ? C.Y1 Well ID# 9S ft. ` / 5-ft. ri,,,,,,,, j/�5a.Well Location: is ft. t% 6 ft. Q bv� e„1C XTrOkV i5 P06001 V/4/M /G ft. D . ft. j,u ^�Ji"! `c `r-1-
Facility/Owner Name J 7 �Q Facility ID#(if applicable) ft. ft. l• /
y't71 6 z DI ft. I , ft. .
Physi
iccal AAddress,City,and Zip ft. ft. '^� ,M i'4 1 r-'r
eal ti/b4 21:REMARKS . l :1..
MAR
f__V E. Lo ..
County Parcel Identification No.(PIN) 1V1AR 0 4 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) �j �r 7 22.Certificatio : t-,-,fiatien ?r'^: 4if-:g tircit
� .5 g 6q N d /, Pt l Li3 W G= ! Mov Oi 30G ! 'a 7 7
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature of Certified Well Contractor 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 EtNo ISA 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#2l 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:' �j< 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V J (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if Afferent(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: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
I '
6 1/8 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 rY 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) Li
Method of test: a j r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
granulated chlorine i Q, 07
13b.Disinfection type: Amount: YYYY
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018