GW1--04702_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: -
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1.Well Contractor Information:` •
-&.iY lec. lb 3 `✓ • ,14• ATERZoNis ,;. •;
PROM TO ' . DESCRIPTION
Well Conttadror Name
ft R
"A ft. ft
NC Well Contractor Certification Number ">15 OUT7:R'CASINGIfiir multi`cased wi li OR'•I'sINER-(it:"a'-`llratile)r .. k.sM
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
.1 . ft. 10 ft. 6 1/8 . in. SDR21 PVC
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Company Name �16` R CASING;ORaT[IBING(geothermal:clwe =loQP) :� i F`'s``'=t 'K
2.Well Construction Permit#: 141� 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):, .
.t 17isSCREEN y< a u '`$%�.+ -,' ' x.--s''.+. 'ia•._ '.Mi.`-`E M ;h?: ±: -�`
Water Supply Well: FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public . ft. ft. in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) s tGi(oUT1Z " . )'' `- = '" n
❑Irrigation . ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft bentonite poured
CI-Monitoring ❑Recovery ft. • ft..
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
,19 SAND/GRAVEL PACK:(ifiapplica-ble)k - .�:t3am5` t1, ."r" s.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage • ft. . ft.
❑Experimental Technology ❑Subsidence Control • ft. • ft.
❑Geothermal(Closed Loop) OTracer 120.DRIIt ING"l%'OG(aft:ch addriiiiii `ehe`eta if neceasary)>w 'r -,. "fix x,- ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/roektype,grain one etc.)
ft. 3,b ft
4.Date Well(s)Completed: •Z7. 21 Well DM fe) ft. T U ft. ye/
oiA 1
5a.Well Location: �g ft;
`�_ �ft- rz,.�a inn��t "
6 /� -, '�'pA7 5 ft- 'S'J'S.fc. £-7","l'
Facility/Owner Name Facility ID#(if applicable) I . .
3 O kaJ'; 1 Or ft. ft.
924
Physical Address,City,it and Zip ft. _ ^ i r `� ,
a ;i21PREl(•L11 '" ci _ -g„
County Parcel Identification No.(PIN) lac::
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fieldjne lat/long is s( rem) 22.Certifica'
c -", Ls o _✓ N / 7 i 3 • W /' " 11/
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of C ed Well Con r Date
By signing this form,!hereby certrfy.that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or I!JNo 1SA 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#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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I ,\ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j� • (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example- Q20 and 2@.1 p00
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: (ft) 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(WC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ro`+a r 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
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FOR WATER SUPPLY WELLS ONLY: ' • 24d.For Water Wells producing over 100,0.00 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)
Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated-chlorine �117
13b.Disinfection type: • Amount: 6 C!6 J .
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018