GW1--04703_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
� i14:WATER`ZONES ,"; ;t:,;..t'6 t
Well(Contractor Name FROM TO DESCRIPTION •
"1 5 s Co ft. ft.
ft ft.
NC Well Contractor Certification Number -=15 OUTER CASING(fdi mniti=caied:welli)UR'LINERTll iiii Lcable);-r Q a'
Morgan Well & Pump, INC FROM T DIAMETER THICKNESS MATERIAL
1 ft* n ft. 6 1/8 in. SDR21 PVC
Company Name ! 1 _, Q /j .
I `//1C�l�V 16 INNER. G;ORsT[TBING(geo`thesmalcldi'edloo�;. tom_
2.Well Construction Permit#: FROM TO `DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft' m'
ft. ft. in. -
3.Well Use(check well use):,
:i17.SCREEN w:3.)itc L`.-g Vr•.'•Fa:.`.,`._,. .. _1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) t tyesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IDECGROUT 7: aUatt': W::..°:`
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 ft bentonite poured
OMonitoring ❑Recovery H. - ft
Injection Well:
ft ft.
DAquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL_PACK(if applicable) .. -
DAquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft
DExperimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer .20 DRILL'ING3 OG(efficfi'aaditional5heefe if iieceasary) 3 . - _.;`: _,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,setrrock type,grain size etc.)
l 0 ft. �j, ft. ' a,e 3 rif _
4.Date Well(s)Completed: L Well ID# .rU ft v ft Die iv II r,� ,
5a.Well Location: Ciro
f / /ft. 1✓Rlllb W n((vjjtech.
( Meci 9AMt (0 ft ffyy1 tJ ft C7 lrU'J
Facility/Owner Name Facili ID#(if applicable) h ft R- ' t
33 C104 e� 1as ft. �. •.j. —1 '
I 2 CO?4
Physical Address,City,and Zip ft ft A l�G 1 �+
�� 5 /! 21'1REMARKS - - - a ,:§5
County Parcel Identification No.(PIN) ^�pp •'
L l. - _.l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if}yrell fi yid,onene latflon�gg is s ncient) G j 22.Ce ' t^�o •
N2 7_j_.,
6.Is(are)the well(s): l]Permanent or ❑Temporary Signature of Certified Well Contractor 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 InNo 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#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: , \ . 24.SUBMITTAL INSTRUCTIONS
9.Total well depthl `below land surface: G �J (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 2Qa 1Q0)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: 30 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota'1�/ 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 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 'o Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine /
13b.Disinfection type: Amount: V -2-01,-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018