GW1--04023_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only:
1.Well Contractor Information: ' • •
J at l-06Q 7-6 ga WArff.R.zor>Es: m . m -a. -.- _ . _
WellCont[a rName FROM TO ' DESCRIPTION •
/� � ft. ft
C1p—� / ft. ft
NC Well Contractor Certification Number '±r15 0Vf$R`.G'ASING%(formnl£t=:cased::wetL+`ORIISIERRliEa'llelible')RaV it
Morgan Well Pump, INC& FROM TO DIAMETER THICKNESS MATERIAL
Company Name �.} ! 1 • ft ISl ft 6 1/8 in' $DR21 PVC
P Y I 'V 7�O b <:Y6:•O1+iNE1t:CAS1NG OR;TUBl1iIG:(Aeottiermal eloaed logp} •:-
2.Well Construction Permit#: ! 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.
:`1711S.CREEN:ti..3<.seisi+�^G-' r "apt z.u�t:.iall t>u;T2?— Z. -:_ _2..- -:�=
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Ltesidential Water Supply(single) ft ft. in. • • •
❑Industrial/Commercial ❑Residential Water Supply(shared) gIrGROIIT .., £" '' °`~ :
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ftbentonite poured
DMonitoring ❑Recovery ft. ft'
Injection Well: • R ft •
❑Aquifer Recharge ❑Groundwater Remediation
• :rig tSAND/GRAYER PIACK(if applrca-ble)- ° '.` .5.,ti r' i
❑Aquifer Storage and Recovery ❑Salinity Barrier . • FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stonnwater Drainage • ft. . ft.
❑Experimental Technology OSubsidence Control - ft. ft. '
❑Geothemnal(Closed Loop) OTracer '120DRLLINGZOG(a `ciihlitionaldeaif neceasaiy)s '`7 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiFrock type,grain size,etc.)
4.Date Well(s)Completed: 4. '67 6 Well ID# `/-y 6 t. 6 '�ft. $i'- ' 6-1(�\,l/� ,
5a.Well Location: ( ft'. q Zft• i2 ['j ,.(�cK. -
5,Al I-��L 1 I ft. 1 o ft yeilowGi�y . • •
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Facility/Owner Name Facility ID#(if applicable) ) ft J� 'f'. c'w-(� 54,y� �,y
N t 73 y..svv ft. �1�%/ ?a4('—, . _(_tJ. „ .. -
Physical Address,City,and Zip ft. ft 1f ' +R/ i
I� .h21LREMARKSac,•.ta h4-ig.r .:. L.._ -
.-+�``_�. + _ . _ '--n.
(_,i4 OJUL 0 S ?024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +.,r, i,M
(if well field,an����sufficient) ��-(1,�� 22.Ce • n: If�ffl.;7^.'sA���Sf�//'� ��J
35 `y' N , `�' r! Cll
6.Is(are)the well(s): IJPermanent or ❑Temporary S' of Certified Well ntractor Date
By signing this form,'hereby certify.that the well(s)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MN() 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 beenprovided 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 GeoprobelDPT 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: I 7 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'L l (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3( 200'and 2Q100')
10.Static water level below top of'casing: • 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+ )
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter 6 (in,)
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) I V Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount: q s'- , •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018