GW1--01386_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 15...",. 1 '
r
J0 M40 14 14.WATER ZONES .
Well Contra or Name FROM TO DESCRIPTION
( / ft. ft. I I
cf
�c6-A ft. ft.
NC Well Contractor Certification Number
•A'
.415..OUTER'CASING-(for mall casedswells)OR:LINER'(ifap licatilej.. G
Morgan Well & Pump, INC C FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft• 6 1/8 j sdr-21 PVC
Company Name
2.Well Construction Permit#: b
1-1 W(1 r_,A. -a 2 �1 1 .°16.:INNER CASING;ORS-TUBING-(geo`lhenmal'closed loop). ,.._ , _ .
3 �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.
I7::SCREEN ...,
Water Supply Well: - ... _. ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) 041.esidential 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 it bentonite poured
❑Monitoring ❑Recovery ft. ft. I
Injection Well: ft. ft.
i '
❑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 shee(s;if.necessary)x;.:'` .,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.) L
I ft� . 3o ft. �� ��l�
4.Date Well(s)Completed: i Well ID# 30 ft. 51 ft, 5 k,> t of 4
5a.Well Location:v 'A 5a1 cj,J ft. r ft. �'/vIle 6.7��,
90A I e A / Cclk ft. ft. tG
Facility/Owner Name Facility ID#(if applicable) ft. ft.
O6}‹ yti/l /d ft. ft.
Physical Address,City,and Zip (• ft. ft. l
1.)V7 .o l/1 21'.REMARKS. .r, _._ _... . _.. ,:!::',,.',IF,:- -:,.::: . q,= .S
County Parcel Identification No.(PIN)
{la Iv.LI i:i1 1.0)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) /1 22.Certification:
/ l � Mart 0 4 2024
( _�/5/26r N /f!,�o d d W 3, 2u
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature t ell Contractor DwCt.BOG ate
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 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 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-I 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: Litic (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')
/ 24a. For All Wells: Original form,to Division of Water Resources (DWR),
10.Static water level below top of casing: CO (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 1/8 24b.For Injection Wells:Copy to D,WR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 depart lment of the county where installed
FOR WATER SUPPLYr WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) c7 Method of test: air -- - Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine 13b.Disinfection type: Amount:L1 • 5 ea. C_i _
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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