GW1--03978_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
.Well Contractor Information:
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Y n Lu Y-( h 1 7 VV i1
ATERZONES
FROM TO DESCRIPTION
W 'ell Contractor Name /�
485 5..E ifq 9° f. ZS 9p"'
ft. ft
r& .24. Well Contractor Certification Number
?15 ODTER:CASING(for multi=caied'.wells):ORI;INER'(If.ii"liceble)':'
' Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. e7 ft. 61/8 in' SDR21 jPVC
•Coinpany Name 4.Well Construction Permit#: JWai 16::INNERCASINGORTUBDNG eothertuareloe )
bdloo -
FROM TO DIAMETER THICKNESS MATERIAL
4,.. List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): • ft ft m
Water Supply Well o17•SCREENS4:,"•.' _, F:r'r. :. ,.':..x .-,�;,-`3.t .,
FROM TO DIAMETER SLOT SIZE THICKNESS ~MATERIAL
❑Agricultural ❑Municipal/Public ft. p, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. .
❑IndustriallCommercial ❑Residential Water Supply(shared) '18::GROUT ..:: _".. y.^ K.I -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
OMonitoring ❑Recovery ft. ft
Injection Well:
ft. ft. �,,
❑Aquifer Recharge ❑Groundwater Remediation #,
i_19:SAND/GRAVELPACK{rf applicable)_. - •.. ,;.:.,�
DAquifer Storage and,Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage Pt R-
❑Experimental Technology ❑Subsidence Control ft ft.
O Geothermal(Closed Loop) ❑Tracer :`i20.DRILLINGLOG OitliiiIiiidaitionallbeeti if necessary) ' ^ •
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D R F O R• b
4.Date Well(s)Completed: Well ID# (C ft. So ft. ie)-Ohli\ ,�4 et5a.Well Location: 57 t 165 ftG tyyy - G fi
Facility/Owner Name Facility ID#(if applicable) ft X, C
1cI'ver� lode �� ,del eiiii N� ft. ft. JUL 0 2024
Physical Address,City,and Zip ft. ft. l�
G ],j 4 21 REMARES' . .' it#c1>s,.,11;iii;;74tir.:4 ,.::,_". - .
County Parcel Identification No.(PIN) Q (:Jrl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon�gfis sufficient) 22.Certification:
,s5. ZS%zy'I N "qi , a1� '/' W /—Z�—Zy
6.Is(are)the well(s): nPermanent or ❑Temporary
Sign e of Certified ell 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 MNo 15ANCAC 02C.0100 or 1SA 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: I24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16'5' (ft) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths if different(example-3Q200'and 2(41100) Y P
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: c7 (ft)
If water level is above casing,use"+"If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 (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
(ie.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) 2 5Method 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