GW1--03977_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
V O.Vf Lu V..e. \-`-! VV crA-c,r 14..WATERZONE3
Well Contractor Name PROM TO DESCRIPTION
- ii-US5A 71° ft. 2Jt ft. 19PM
ft. f.
NC Well Contractor Certification Number =.15::OVTER.CASING(foefi ulti dii'ed'wells);ORLI NER'(if.a"liable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL _
• 1 n /GO ft• 61/8 in' SDR21 PVC
Company Name /Li
2/['/ :1r6 NER CASING:OR•TUBING(geothermildoeed4cido - . -
2.Well Construction Permit#: 1J / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft- ft.
3.Well Use(check well use): h ft. In"
417:SCREENkl.-;*.-.._,: 'd igq.-i:=.r-, ?:--;:.;b•cif •; ,s'. , : .... . :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS':; :M:.:.ATERIAL .
❑Agricultural ❑Municipal/Public g, 11, in.
❑Geothermal(Heating/Cooling Supply) Biesidential Water Supply(single) ft. R in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) :18GROOT
Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft' 20 e• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
a19::SAND/GRAVELPACK(if applicable):::- ''.;t•:..:, ..
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage N. ft•
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer '':20.DRILLING.LOG(ittadiadditionileheetiif necessary).-. _ -
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: 10~17~2"1 Well ID# 3 l ft. 6 $ ft 3/,-0✓I ky'J/f r
5a.Well Location: 6 q ft. I c el ft. D t-oVA ,54.4- , `C� i VE D ..
R 6l i Yeu jeni y 156 f• 3115 It. 6k.91 G"API JUL 0 E 2024
Facili Ow l nerName ,} - Facility 3 � ft-' 3 S B' /'it/'IL 6A-411 s
IO[/O J. 11�./ik,W17A. live_ "It }gypj)y/ 3sefr. sOjft. 6hit,t/ G1x„� InfernLRirro1 ?'- g:1 utt
Physical Address,City,and Zip
ft_ ft. / EM Cd SOG
64j //
td ! 21.RF.MARKC .
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) l/ 22.Certification:
✓S , ZRISIOf N - 4114397f W IP', 1/ . 6^(`/✓M
6.Is(are)the well(s): I•lPermanent or ❑Temporary Si of Certed 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 ONo 1SANCAC 02C.0100 or 1SANCAC 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: COO (It) Submit this GW 1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3Q200'and 2Qa 100') y p
10.Static water level below top of casing: • 50 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 Cm) Program,
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
13a.Yield(gpm) 1 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