GW1--04743_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
•
1.Well Contractor Information:
3 0\)\•\ 1—C6C\ '6.-‹b 44.':WATER'ZONES, ,.�4;.kxe./ aei x;iii ..iiiZEVt..-Zicr•.AlkA3MSAt
Well Contractor N a FROM TO DESCRIPTION
ft. ft.
ft. ft.
NC Well Contractor Certification Number '-'35:OUTERCASING(fo$mnit?cased we'hlsi OR LINERXEap 7tcable) 14
Morgan Well & Pump, I N C FROM s -TO DIAMETER THICKNESS MATERIAL
1 `�t' ft" 61/8 in. SDR21 PVC
Company Name IlVNER CASING;O RRUBING(geu£heimal closed loop)';"'s.
2.Well Construction Permit#: IC/ �� Y6FROM 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.
• REE
Water Supply Well: FROMl • • •
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft. in. •
❑Industrial/Commercial ✓✓❑Residential Water Supply(shared) 18 tGROtiT; . `77 MkingW exP:VMM - .,gia• t' X:.
❑irrigation ❑Wells>100,000 GPD FROM - TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20 ft• bentonite _poured
QMonitoring ❑Recovery ft. ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
>;19 SAND/GRAYEI:-PACK(>f_applica"ble)'i.' .. r. 3•.3 .
❑Aquifer Storage and Recovery 0 Salinity Bather • FROM TO MATERIAL EMPLACEMENT METHOD
(=Aquifer Test ❑Stormwater Drainage ft R-
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer =2D-DRIII:IPTG. G(attach3additioniritieeti if i eceaasry) _ ,:_
FROM❑Geothermal(Heating/Cooling Return) ❑Other(explain tindei:#21 Remarks) TO O ft D TION(colar,,ardaess,soil/rock type grain sire,etc.)
1 -C_.G1� O ,TTLL
4.Date Well(s)Completed: `` �� Well ID# 3 ft c S ft B route, i; � 1y
,
5a.Well Location: S ft ) ft 'a/N6 -
CUI(& � ;i: (i ' e, BU;t3'2rs ibft' Its ft f�roWr\ foci :- ,
tyFacility (ifapplicable) I10 ft- �.2c'ft. . Gl fa A J.'ts , •- w�i:_: ,
Facility/Owner Name ID# a licable 1 �••
\4,1S4 C—t0..IlNci\\ p( 4huitYvk--EY1 ft.
f. AUG 1 2 2024
ft. ft
Physical Address,City,and Zip
C� .11.REMdARLCCLL;:. . —3. - :.;►I'P..PiVfn'''tell:. itap 2.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific •tr :
3� .3f7 N ). ZI117/ W 7 3 -Z
6.Is(are)the well(s): l lPermanent or ❑Temporary Signatur f e ed 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 PJNo 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 section 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: i7 (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 2@100"
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of'casing: 140 (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 O•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ro`a'1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
v�
Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
granulated chlorine v�}
/ 0
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018