GW1--04039_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW 1) • For Internal Use Only: ,
' 1.Well Contractor Information: ' I
` Z d� i1:4r:WATER'ZONES.ai w,'ir1ti'9's t."1.'eta?`-.14'zl Kiiit T.I s; ':... -. h
Well Contractor Name FROM TO • DESCRIPTION •
• ySS��^ ft ft •
ft. , ft .NC Well Contractor Certification Number 15a3UTZEt'QASINGI(fo%mntfi`-ca""sedwe7.lai ORIiINERjif.a"'hcable) a
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
Company Name .1 • ft' iyi ft. 6 1/8_ in' $DR21 PVC
/� Z �:t1KINNERCASING pRA'UB7NGWO'lliar al:clbaecl'-'logp)';':.:
2.Well Construction Permit#:di !'/It2...409 ✓c>s I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ounty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):, ft ft in.
"-::17SSOREEN.•F'v&flr itie `'.`sa •,.t'RC ,v °tom.``�`V---•;>.r�a ::..,:- >'-:--A
Water Supply WeII: •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
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❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft. in- • ' •
❑Industrial/Commercial ❑Residential Water Supply(shared)
11$M.RUUTasira="Zgri? �ar. i .XVKtu,"-"f4;4>I; ���it�'�..�".ar,10<-:as
❑lrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
❑Monitoring ❑Recovery ft ft.'
Injection Well: •-
• ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
119 SAND/GRAVEL:PAC'KCCLaPplicEb1e) '� :a t,AWAt r.: .•O J.':f. i
❑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) ❑Tracer `.;20AiR11tL•INGIOG"lat}ich adiiitiorifilelieeis if i ece"esary) r
FROM TO • D CRIPTION(color,hardness,soil/rock type,graindne,etc.)
0 Geothermal(Heating/Cooling Return)/t� ❑Other(explain under#21 Remarks) T. ! f�ro` `�
4.Date Well(s)Completed: 5`-30-L'11Well ID# S 7 ft. 0Aa (Zi�'- •
5a.Well Location: _t ft It•7 7 ft- ft. C(�//\ ti ,`a ti
e4are /Ylare h r. 71 ft- ITs ft. cnrovnxkR `�-�•6. '✓ED
Facility/Owner Na Facility m#(if applicable) ft ,1 i J L 0 v Q 2/J
N /J�l ft. ft. U24
$q oats � rafJ i` -" ft ft 1f ivr.':'i,i:.•,I a�:.:t R •
Physical Address,City,and Zip v
f-a W r A _ �j ;sac i
Uzi:RE11reTucs.. r,.� {.,. .. ..._. , _§
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certific on:
� 503 N ' 1. °IL6Q W C _I /_ Z41
6.Is(are)the well(s): ('Permanent or OTemporary Signa f Certified ell r Date
By signing this form,I hereby certfy,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 1SANCAC 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 sgction or on the back of this form. •
23.Site diagram or additional well details:
8.For GeoprobedDPT 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.
dulled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depthQ below land surface: 2 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example--V 3@,200'and IQI00)
10.Static water level below top of'casing: 4/0 • ) 24a. For Ail Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (m,)
Program,1636 MSC,Raleigh,NC 27699-1636
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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) Method of test a I r pressure Permit Program 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:g•ranulated chlodne Amount: l0 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018