GW1--04038_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
' 1.Well Contractor Information: ' •
3-01� TOl S1_ 4wxTEx'zoriEs ;;
Well Contractor Name FROM TO DESCRIPTION •
f. ft.
NC Well Contractor Certification Number '15EO111'ERQASING fomTifnlft=eased wells ORYIPIER.7if.s"7lcable •'
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Morgan Well & Pump, I N C FROM' TO DIAMETER THICKNESS MATERIAL
1 ft. LiS ft 61/8 in. SDR21 PVC
Company Name g..,
QQQQ 2 '/(� ;t10INNiER:CASING;ORC`UBlliTa eotheimar:eloiei lgop).1fal � ":f'x <.
2.Well Construction Permit#: VI( 1 L( ]1 li_O� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc) ft- ft. in.
3.Well Use(check well use):, ft ft' in..
Water Supply WeII: .17ZSCREEN; is''s. 4� *u- - • `1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
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❑Geothermal(Heating/Cooling Supply) XIResidential Water Supply(single) ft ft. in. • •
❑lndustrial/Commercial ❑Residential Water Supply(shared) sr a:. c +t; s' i �'� c
,j;B.GROI]T3'sSe�.rxar2�r.ASS,3r.' ;::z;.._'iti.;�,.,_atx"l`d:_�'Y. .,�`s..'tisx. d,.�.ar.
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 t bentonite poured
(}Monitoring ❑Recovery it. ft.' •
Injection Well: -
• ft. ft.
DAquifer Recharge ❑Groundwater Remediation
39'SAND[GRAVEI::PMZEF a -tic5tile": . -
❑Aquifer Storage and Recovery ❑Salinity Barrier . • FROM TO MATERIAL ) ` EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage • ft• ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer :2pl B11iLINGI OG(attach iadiHonaLilieetlif iiec`essa=y).,,$i-4 4..t"r�3� n, ..;,_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES ON(color,hardness mO/roelr type,grain size,etc.) ~
(� 0 f. ILI ft .t? CI 1 t
4.Date Well(s)Completed: v_ —Q4 Well ID# I L ft' B . 'y Uu10 dl r-i-
5a.Well Location: 2., ft. Li Q ft r�1 U Ulj 1 Ot
MY{\ TotoGst (-10 ft 2fISf. C"i,�o' +. `,`3VE[
Facility/Owner Name Facility ID#(if applicable) ft ft..
r- Cy'1'7. Ilof,nMoin Cl eV JUL 0 8 2024
Physical Address,City,and Zip
py ft tr;.-•r.44 :1,ttr,.aai IjIRI
l/ .$
C M' )t/\ 21:fRE11MARKS.; a 0144'i `,4
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,i one lat/long is sufficient) 22.Certification: '
5 _`°'3 L/ N ) , Di) �.i5 W - 4/.
r. /)._z .
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6.Is(are)the well(s): CiPermanent or OTemporary Signs f ertifie We ontractor 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 elNo 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#11 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 \ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 i 1 S (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and Kull O0�
10.Static water level below top of'casing: 24a. For AB Wells: Original form to Division of Water Resources (DWR),
If water level is above ca ing,use"+' (B') Information 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: rota'�7�/ 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 100,0.00 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) q Method of test: a i r pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:granulated chlorine Amount:• ei • Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018