GW1--03937_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
P _ -� `, , �/
V O`nfl � V_� h 1 7 VV�iI
Well Contractor Name FROM TO - DESCRIPTION
�s'A 'LZOit. 221 it. '.5 gip
y61 ft. 1162 ft. o.s 1 Pier
NC Well Contractor Certification Number :15..OUTER.CASING(fa i ibi&ci i wel s):ORi1 ER(lfa` lickb1Wl,:.,:::-.' .'
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 it. 1�(,� ft. 61/8 in SDR21 PVC
Company Name �/ ,.16:'.INNERCASING.ORTUBING' eothmii erTeltiled=lo'o
2.Well Construction Permit#: Q D 7 S I 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.
4172SCREEN w;i.:: :.t. ;:lHadL.- j ";?s)i `:1'; ::'`y.`.:::.„i:i: .':;:'.';..
Water Supply Well: FROM TO 1DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural . ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) glii4idential Water Supply(single) it ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ;18r,GROUT::";;'' :' ..>>...;;i a<" _ ;<Y'� -:-�;t ;%
❑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.
DAquifer Recharge ❑Groundwater Remediation
::19:-SAND/GRAVEL'PACK'Of'iipplicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer =20 DRILLINGLOG cattiielfildaitiOnaTilieetiifriecese ?.ill.""'
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �l R ,S R n r�
/ V Pi kJ' `
4.Date Well(s)Completed: Cl -Zg-z Well ID# i6 "• SQL ti• A. �j&yt�l�"
ft f.
5a.Well Location:
/I).�y 5di 5 ft ft. .`� '�
-Facility/Owner Name Facility ID#(if applicable) ft ft. - -.��.�1M jt
Zid 7d J-J- 5/ s4,s/iry iiG 2gI`1y ft. ft JUi 2024
ft ft.
Physical Address,City,and Zip Y h,`-, Ir�; �i�.a-�N
ko'l✓61./✓ q 3 0 A '2- r21SZtEMARKS ',I.:.-,-'4 . .;::. 2.04:.. _AHQ:,t:Jay
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) . 22.Certification:
ss„ 73I:51 N -so,ei gzsco w sL6 ; 6zg_Z`-I
6.Is(are)the well(s). nPermanent or ❑Temporary
Signature of 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: DYes or l!lNo 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#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: Soo (ft.)
For multiple wells list all depths if different(example-3 a200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S (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'1r�� 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
2 air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018