GW1--05352_Well Construction - GW1_20240909

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
jContractor Information: '7`-V1
O'flfl W Y e. h 1 ! V o—I-e. 14:.WATER ZONES ::
7 FROM TO DESCRIPTIONWell Contractor Name A Q() ft. (J ft. + p
fI �s5 /` ( 0 1 1 y F M
`� sf�` ft ft.
NC Well Contractor Certification Number i15:'.OUTER.CASING(for multi=caied*e1Lh);ORIANER(if.a licableyl-:'..:: . '
Morgan
Well & Pump, INC FROM TO DIAMETER THICIINESS MATERIAL
p 1 ft• �(q it 61/8 in. SDR21 PVC
Company Name ,� y `60063
0 3 ,16INNERCASING:ORTQBING" eottiermiilclo"sed:loo
2.Well Construction Permit#: //' L v FROM TO DIAMETER — THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
f. ft. in.
3.Well Use(check well use): •
417d SCREEN'S`. ... :5'Faf 6t.'•,y _, ,; .i..".1.-. -.' ::. _. •2:`.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERrer.
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial DResidential Water Supply(shared) :18;.,GROUT::—'-'. '' ..`c'.:,::''.. : ;;<t`=e .�'_'.glc'`:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft' bentonite—poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft.
DAquifer Recharge ❑Groundwater Remzediation V�`
:119.,SAND/GRAVEL PACK'(if applicable) .
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
ID Geothermal(Closed Loop) ❑Tracer 20:DRILI INGLOG(attaclia'ddifional eb'eeta`ifneceaasry) 'r .•:' t-;
... ._. , ..
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft ZZ ft 1Qp�-- t
Q r_" j-Iv
4.Date Well(s)Completed: v /1�Z1 Well ID# .. 2 3 R' �d"' 6k-Ay `4 hfet ^ -*,`
ft ft. r % `I LR E i.l
5a.Well Location:
5,1)17 5fp^4f vi/ r► isfe'e- ft. ft SEP d 9 2024
- -Facility/Owner Name Facility ID#(if applicable) ft' ft'
'it'I I ST 5/p4e45 41,,1,4 k— L Z'O-1 ft ft Ird:,:,-: .f r' -r;�.. v
c.t et
f. ft T 016';ef1•�,o
Physical
Address,City,and Zip
C.L,6a-r-h5 ;21:REMARKS I'';-',i ,- :..?v: %.` . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one 1at/long is sufficient) . 22.Certification:
.j5, Vs'y8'9s7 N — .3 722931- W '1) ,
g`l5 Z
6.Is are the well(s): OPermanent or ❑Temporary Signs a of Certified Well Contractor Date
By signing this fonn,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 ISA 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: r 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: !o (ft)
For multiple wells list all depths if decent(example-3@200'and 2(a3100) Submit this GW-1 within 30 days of well completion per the following:
L�d (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 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(IUC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota'J 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) l 6 Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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