GW1--04785_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J Q� \ "C`iii 14'WATER'ZONES. :M ,._.ad. ,3. ,
FROM TO DESCRIPTION
Well Contractor Name Vv
dcp5 V-- ft. . ft _
NC Well Con✓✓tractor Certification Number -t15 ODTER:CASING`(for•�ulti-ca+ed:.we1Li)OR IiINER(if ap'hcable) - ``+ >,
Morgan Well l l & Pump,m , INCFROM T$ DIAMETER THICKNESS MATERIAL
p 1 ft' Q j ft 6 1/8 in SDR21 PVC
Company Name (J .' L\-O\ S 6 V ;346s NER.CASING .._ __.-
'IN ;OR:T[TBIPiG(geothecmal closed]o op)''._
2.Well Construction Permit#: 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
17:-SCREEN'.f. al-E4.ih >'i 'lilH Lt `. a s '"r tkl. .u.:s:' _,.i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft ft in.
DGeothermal(Heating/Cooling Supply) pesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) x t r .6K ,4"", , , Tf-‘
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n• 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.".19 SAND/GRAVEL PACE if i{iplicable)' r. ..,' S .#.": `,a`
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .:1l2O-DBILLING`LOG(aMach;additionalelie`eti if iieceaaaiy),; Z
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
7�-ti'LH eft. tkc: ft. d,n.
4.Date Well(s)Completed: Well ID# b ft. , ft. ^ \\ p _O
5a.We Location: %ft. -�/ ft. bf '. -z[,n�
ASK►t, Sl;(1r o9f ft toy ft i o . ".- . . '
Facility/Owner l ame Facility lD#(if applicable) R ,ft. .' �-,' _ F •� •c,' 1.. 1/1 T ,j
UO2C Nc- is l ft . ft AUG
Physical Address,City,and Zip ft ft �' �Gt?4
J{"f. ,1 U-r)!
County Parcel Identification No.(PIN) D c*,It-,;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certifi tion:
5S.qd 70 N 41 . 6 aI+ W 7 4t'V1
6.Is(are)the well(s): [ Permanent or ❑Temporaly Signature of Certified ell ntractor 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 ONo 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: 1 \ � 24.SUBMITTAL INSTRUCTIONS
Q
9.Total well depth below land surface: 0' (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiffererit(example-3Q200'and 2Q100�
ig24a. For All Wells: Original form to Division of Water Resources (DWR),
c
10.Static water level below top ofasing: (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(MC)
11.Borehole diameter (in) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary 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
60 air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
granulated chlorine D�
13b.Disinfection type: Amount: 111 •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018