GW1--02861_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
J O`nfl LU \te �'_1*7'S1( l/
•14:,WATER ZONES ••..•.-,;; ......'1:-.'...__ ' -•L.: _..
Well Contractor Name
FROM TO r' DESCRIPTION
Q S 3 A r�D ft I b Z ft. Li pn"I
ft ft.
NC Well Contractor Certification Number
?:151:O1:fTER.GrASING(for'multi-cated'.welU):OR•LINER'(if.ap licable)';:.,%':.:•:.::`'
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft' 75 ft' 61/8 i°• SDR21 PVC
Company Name
I-0 2M ." 060`13 ,IBtINNER CASING.OR'TIIBING"(ieeothermn1 e16sed loopn.,,r.,,A:_,•;,:„::.-:';::
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): • ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICIQVESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. ,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) f.18`GROUT::: "`:_ ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20 n• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: -
f. ft.
❑Aquifer Recharge ❑Groundwater Remediation
r_19::SAND/GRAVEL'PACK(ifappphcable):::•- z:'•; ,_ ...-% ;y.:5:.�.= '
❑Aquifer Storage and Recovery ❑SalinityRan-ier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal Closed Loo ❑Tracer S'20i3)BILLING,LOG att'a`cli'a'dditionalsh"e'etsiflie"ceeia a i _::,if•`• :
oGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remsrkn)A/ FROM To DESCRIPTION](co1ar,hardness,saiUzocktype,grain sizeetc.)
4.Date Well(s)Completed: %`//q 2�// 0 ft V ft' Rc - d-j
r Well ID# 2-7 ft' 3 5 ft• BY-CPA X'i rit
5a.Well Location: 3 I ft G Z ft' ig kt)hill '€ ,- --
LU/'rZ /11&1oz &ZQU Z 63 ft. 42 ft. Gay 6k•sA.i{t
Facility/Owner Name Facility ID#(if applicable) '93 ft• /7S ft pm k' 61-h.,*
//ZG P,!,e si k.e mct pdfis /tC- 17 ' ft• 2 -5ft 61-,,y 6,- c • , .-.r
Physical Address,City,and Zip ft. ft. !�\ -•''a•••i ]T.,
`Ra l„ -AA ::'.21:REmARKR=y{..=ei 2---•.:'; i I ri�� n
I 0. 2024
County .. Parcel Identification No.(PIN) I,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: if'"" "4 a '• " ' "`:,t
(if well field,one lat/long is sufficient) 22.Certification G,L..f y4a
;7s 1i9�1 2-‘3 N -go. 6 czyy63 W �� -19-Zy
6.Is(are)the well(s): C1Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,Thereby cerhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z.Z.5 (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@I00)
L/D 24a. For All Wells: Original form ito 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"+" p
11.Borehole diameter 6 an) Program,
For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
rota i
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
i •
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) L' Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018