GW1--04040_Well Construction - GW1_20240708

•
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
• 1.Well Contractor Information: ' • •
7G�1-0 --- 4e c14,Wi,TER'.ZONES: Mwla�R
Well1II Contracto Namne PROM TO ' DESCRIPTION •
YS —n ft ft. .
�` ft. , ft
NC Well Contractor Certification Number '%15`OUTER'.Oi1SING?fo%mnlii4easeti::weghtliOR•LIIVER(iLap Ileih e)
Morgan Well & Pump, I N C FROM' TO DIAMETER THICKNESS MATERIAL
1 ft' (00 ft' 61/8 hi' 5DR21. PVC
Company Name _
14111 �/1 _ Y/(C9 r 1P ..16`;11tIl� ICC MNG:OR-TUBINGtiliiilieciifire `-liaii)l,Ia ' 5.:%'s 7.4-.«t'
2.Well Construction Permit#: V�� � •"� �Y 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.
I173'SeREEN;rz ii-i. :e --. a,. a . + -,.'.1.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public • ft, ft. in.
❑Geothermal(Heating/Cooling Supply) "Ntpesidential Water Supply(single) ft. ft. in. •
❑Industrial/Commercial ❑Residential Water Supply(shared) girGRQUtzssS " 'ti i : tiSY"wt°-'n ;, ``=. •" _
❑irrigation ❑Wellls>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft' bentonite poured
DMonitoring ❑Recovery it. ft.'
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ':I9 SANDIGRAVEL:EACg(LEappiicati1e) sue;. _
❑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 :20 DRILLING LOG r[iacfi addrhonilslie'etiif neciiiiii')i;gi'';f,., _ ::
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O . ft. PLC
ft .^n C' `;�-1-
4.Date Well(s)Completed: S Z91,--74 Well ID# 2..c
ft. •0 ft. $Q)(//f c 1 r-} `
5a.Well Location: ( 6 ft. C ft (' . ' r
7 & M proper— < 55ft. e�•t7Oft. .rota ;. '
Facility/Owner Name Facility lD#(if applicable) ' ft• C/ 'ft. J U L 0 8 20 24
Z9 7 Z, Q 1 i2 ft. . ft.
Physical Address,City,and Zip ft ft a�'�^r��y
Gr'`l}ctvbk G2xrRENTAIIKS i*4:, O i' rieUi14 _ : 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) �j 22.Certif. •' n:
gn'457s2 N V 24 c-q W (n `I l~- il.
6.Is(are)the well(s): I•IPermanent or ❑Tempora/ry Signature of ertified We Contractor Date
By signing this form,I hereby certiifr that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fiNo 15A NCAC 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#2I remarks sgction 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Lr 0 (R') 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: 7 ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.St level is above casing use"+` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
tfwater11.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'1-Y 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 100,0.00 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /5 Method of test:air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:9`anulated'chlorine Amount: 1p • 3 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018