GW1--03959_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:i w J1
O YI f LU� �e � 1V Ik? Cri-C, '14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name A 4U5 as- n. 2.2C f• Z5 6N4
NC Well Contractor Certification Number `.15.:OUTER CASING(for fibula:eased wella)'OR LINER'(if ap lickble) .
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL -
1 ft. 1 CO ft. 6 1/8 in' SDR21 IPVC
Company Name 16.INNER CASING OR TUBING(geothernial closed-loop)'::`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.NC,County,State,Variance,etc.) ft. ft. in.
ft ft. in.
Well Use(check well use):
;.17;SCREENi`1.:.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19:.GRODT
Wgation ❑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. -
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK('if applicable) .
[Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach.additional sheets if necessary):'; '
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
2 uh ft. s` ft. raj_ li r)
4.Date Well(s)Completed: 5-3(AZT Well ID# S 7 ff. 76 ft. 13 ati-ot✓' dr
5a.WellLocation: 77 ft' 91 R' 8L,I/4 ► ok. �`s--�.. .t% /•
R 2 ft. t!I'O` ft. p(91s,� G 1.44 f'1' L: V
Facility/Owner/ Name J / Facility ID#(if applicable) Sg 1 ft .ySbq�7 ft /"is/P( 6I ewe* J U L 0 ` 20 e-4
7%2- ki've-v I try AW'Ii S9‘ft /D0 ft 6 6A 4 1f 11-A-v+rsYg,i_3...�. ; i
Physical ell
Address,
`t City,itl and Zip ft ft DA�30,j `�
ri-e -21i RF.MARKC =`, -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
15e 5941(9d N •40. s z9117 W _-3--2 y
6.Is(are)the well(s): lPermanent or ❑Temporary Signature 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: [Wes or ONo 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: , 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7°0 (ft)
For multiple wells list all depths if different(example-3@200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
11 O 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"+"v
11.Borehole diameter: 6 1/O (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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 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-S 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