GW1--03917_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:i �\) _ 1. 1
0Y fl Val, �p V h J �/k7 V 14.WATER ZONES -. _ .. .
FROM TO DESCRIPTION
Well Contractor
5 A fr
tor Name
�!l 1741 ft. ,Z 9 fr. P/n
. ft. J
NC Well Contractor Certification Number '15.OUTER CASING(for multi-wed wells)OR LINER"(if a licable)'.;
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERL&
1 ft. 7/ ft. 61/8 in' SDR21 PVC
Company Name
1 tj 165 16.INNER CASING OR TUBING(geothermal closed-loop).- .
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 :. '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) iXesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18i.GROU r -;
❑lmgation ❑Wells>100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f• 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(attacfi idditional sheets if neccessary)`
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rocktype grain size etc.)
�J 6 ft 1-6 ft. Q J-1 ht
4.Date Well(s)Completed: G.-/9_z / Well ID# 2 / f. '6 q ft. r/�j`HOW,/I acGK
5a.Well Location: /� !a ft p 6i-y 4 "4� ..
,$Gt/1 c i- �l a✓I' ft ZdC) ft. p % �4,L. a,
Facility/Owner Name Facility lD#(if applicable) ft- ft
/OS- Viti^. P/ p t Hoily 2-0 7' .
ft JUL 0 5 2024
Physical Address,City,and Zip ft. ft Ire( Ji irb:P,1 ,a -�ts
G 441aA .21.REMARKS" .., ..`D'd� .T3Og_.. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
3 5. ,?vVoz Z_ N -kl. 077333C w t ‘-2-9 27
6.Is(are)the well(s): (]Permanent or ❑Temporary S' 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 InNo 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: i nh 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !�d (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
50 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"+"
6 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'1-Y 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) g 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 Revised 6-6-2018