GW1--01359_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ContractorInformation: i
I
'J\ lb:Ai
J 14.WATER ZONES . . ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I '
ucc6 44
f[. ft. 1
NC Well Contractor Certification Number INC15.OUTER CASING(for multi-cased wells)OR,LINER(if ap licable)
Morgan Well & Pump, N FROM TO DIAMETER THICKNESS MATERIAL
0 ft• yl ft• 61/8 : in. sdr-21 PVC
Company Name
2.Well Construction Permit#: (
((iD3 Z 16.INNER CASING OR TUBING(geothermal closed loop)'
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.
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
0 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/GRAVELPACI(;(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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO (,DESCRIPTION(color,hardness,soiUrack type grain size,etc.)
) O It. I70 ft. 14
q
4.Date Well(s)Completed: 1r5/-Z1 Well ID# ft. ft. rtav v1ecib Nat
5a.Well Location: '3 i ft. OS ft. 3 Jj 6 I G ved„,�;4_6
QO66- 8c11 ft. ft.
Facili wn�err Name /,� Facility ID//(if applicable) ft. ft. •
[37 ^ bt/1 4y 2 ft. ft.
Physical Address,City,and Zip ft. ft. '
C~a O -21.REMARKS _ . . -
County Parcel Identification No.(PIN) -^.- ...-.m-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' "" L.,L'a
(if well field,one lat/long is sufficient) .122.Certification: IVI" AK 0 A 2024
' S 36 ag N t/`.ogot.i W 1\ )I Z'�
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of C rti ell Con act < ^ DWCOOG
Date
By signing this form,1 hereby certjfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 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#111 remarks section or on the back of this farm.
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:' 7.595 24.SUBMITTAL INSTRUCTIONS:
9.Total well depth below land surface: (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@100)
10.Static water level below top of casing: l� (ft.) 24a. For All Wells: Original form;to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 t 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) /S Method of test: air
•Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount: 6 -5 tr L
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018