GW1--02856_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 I
J 0\ f L 14-e. \ 7 rrei MeV
!:_�•:•': :. - _ .. . ..... _... . ..
FROM TO DESCRIPTION '
Well Contractor Name//T� f ZQ ft. I' ft. 1 d/i/h
�� G� J I
- ` J I �'L`42. it. Pei ft. /0 gpiv-i
NC Well Contractor Certification Number ::15::OUTER CASING'(foi•'multi. ied'.welLs):ORLINER'(ff.zp'licable)';:.;.: :.:;:.:'.:
Morgan Well & Pump, I N C FROM TO DIAMETER . THICKNESS MATERIAL
1 ft. 6Z ft• 61/8 in. SDR21 PVC
Company Name •
3 g 9/2- s r.--
:lti.:INNER.CASING:ORTUBING'(geotherinal clo'3'e'd..-..
2.Well Construction Permit#: 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:"_i,:. ..,,. ,;,i*.fd<'i-'ra: s;:?': .'- :. .._.-:' - ... .'-' , '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural . ❑MunicipallPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) a> • r_.:,,I
❑Irrigation DWells>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
is19::SAND/GRAVEL PACK(iiffapPlicable)'r'•i' :'t.:::'•: ..•::;1.'•':_'-:e:i:.d<: .1: ..'
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL . EMPLACEMENT METHOD
['Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft. •
❑Geothermal(Closed Loop) ❑Tracer 1 20 DRILL'INGLOG(iittacliadditi6nal hlieeti if iece:sliiiy)Eri: :::1::'-•`.' -2:.:?::';•'.'..'
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVzocktype grain size,etc.)
❑ ' N D ft 2 6 ft' RCJ- Ct H1-
`
4.Date Well(s)Completed: 1 I q-2` Well ID# a 7 ft. y g ft. RY6j1 g
5a.Well Location: N cr ft 20.5 ft 6k.y 6i-•A�l;k
kO6e4 iiu I►wn ft. ft.
Facility/Owner Name FacilityID# a applicable) R ft p 7
7.
(ifPP ) (•�
Lyt/Ce.�=�/-t by. Ss.l isbu1 Pc ft ft I J ti .a�,'1... )t..... .,r 1.-,
Physical Address,City,and Zip ft. ft MAY I n 2024
Rap/Ai) 50 2- A 0o7 r21£RF.MARKR . _. ., ...`= ^.----. ....'u' .. �e{•.,. :' ,:,..._?:de-,..,._ < ''^ ..
County ParcelIdentiificationNo.(PIN) !r'F�'""'�.r' '7 J .' t�i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.Certification:
35 6c'6Z136 N -•Ee0 30 3163 6 w G
6.Is are the well(s): CJPermanent or OTemporary Sign
By 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 L!JNo 1SANCAC 02C.0100 or 15ANCAC 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: + 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZO (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: 3s (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in) Program,1636 MSC,Raleigh,NC 2769971636
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
13a.Yield(gpm) Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018