GW1--04021_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
O. It ` ' 14 i.WATERIZONES . 2-. • .
Well Co�n/tractor ame FROM TO � DESCRIPTION •
l '� ft. ft.
ft ft.
NC Well Contractor Certification Number 15c:0UTER'CASING'(fo'rmniti4aiii we7li)ORI:INER=(tf.ap hcable) ;io-
Morgan Well & Pump, INC FROM' TO DIAMETER THICKNESS MATERIAL
an 1 - n' 7j(� N- 6 1/8 . in SDR21 PVC •
Company y Name ' �r16:'1TTNEKCASING ORTUBING(g"eolheimal cla d loop)"fi- fig,:er.,' a" ':`
2.Well Construction Permit#: ( 1J'J 0 1`�cC FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) B. ft. in.
3.Well Use(check well use):, ft ft in.
Water Supply Well 17;=SCREEN'.:gt t NV "F:�:f;FZ.Ti; _ = `=1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public � •� ft ft in.
['Geothermal(Heating/Cooling Supply) , Residential Water Supply(single) it ft 7. in. - ' '
❑Industrial/Commercial ❑Residential Water Supply(shared) g3GROUT; -MX.I' ? WittKVtk:.r" +' Tal
❑Irrigation ['Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f• 20 ft- bentonite poured
OMonitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation t19.;SAND/GRAVF.IIPACK(if_apphcablel'� . ;':<: Z ,,.1'
['Aquifer Storage and Recovery ❑Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage • ft. D.
['Experimental Technology ['Subsidence Control f. ft '
❑Geothermal(Closed Loop) ['Tracer . 20'�IIRILLING LOG(attich-additionaLslieetiif neiiasaiy)FI:y', .''_`. ;
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saWrock type grata aixq etc.)
/'� + y ] ft Z�ft. (fit 1 •-�
4.Date Well(s)Completed: lc �l- lJ`� Well ID# � G �/ � ) ,
ft. ft. .
5a.Well Location:
-Icy/ G2 ��/' Pik ft ri r..._ L.;
Facility/Owner Name Facility ID#(if applicable)
lit 0 8 2824
Physical Address,City,and Zip ft ft .^,4,1.•^'l• -." UIi
:i21ERE111"ARKS. ..3 4;_.,. .:.siti.er� `a�..Dj .d !y r?.1
C /.e,n 1./,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) A ( 22.Certification: •
5S Ifl N �
1 1 l • W _I/
6.Is(are)the well(s): OPermanent or ❑Temporary Signs Certifi We 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 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 suction 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 Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: ' -•` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Sl;a (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a3200'and 2Qa 1Q0)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: Ca (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: rotaCY 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) Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine .l_�7
13b.Disinfection type: • Amount: ( �
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018