GW1--05405_Well Construction - GW1_20240909

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:� i `, 1
) On W 1 �e -I\ 7 V V C['t r 14.WATER ZONES t':,N-' .
Well Contractor Name FROM TO DESCRIPTION
use f/�\/� 'Z76ft. 'Z ft. „Marl
ft. I ft. "
• NC Well Contractor Certification Number '.15r'OUTER CASING(for midti=caied4wells)OR LINER(if ail licable)� - '
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL -
1 ft• 6 7.. ft. 6 1/8 i". SDR21 [PVC
Company Name
16.-INNER CASING OR TUBING(ge'othermal'cloeed-loo
2.Well Construction Permit#: '/ �ii"' ��r/ / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
SCREEN t'.
Water Supply Well: FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑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
❑Aquifer Recharge ❑Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable) ..
DAquifer Storage and Recovery ❑Salinity Barrier FROM _ TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
DExperimental Technology ❑Subsidence Control ft ft.
©Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) .i'Fv+` :`V ' ':: s%'
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a fte.1 21 ft. d 0 _
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4.Date Wells)Completed: 0 2D—Zi/ Well ID# Z -2 H' /b ---.1ft 6- „ 6,, i tt .t--�f L.-: %/c L
5a.Well LocLocation: A/C
// ft ft j S E P 0 9 2024
4 1 i-ee- J '? 14✓1 N/ A ft ft.
Facility/Ow}}nerName ,p/I Facility IDD##(i(iffapplicable) ^/ R ft lf'(D"rr`.tf'` r "' =tidy
2— 5' &M V � �O'— tecc , 'I J'�C ft. ft ri`fi`..o*0-3
Physical Address,City,and Zip ft ft
k_,W/A/1 3') lg3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/lon�g/iiss sufficient)] ci j Q 22.Certification: �f /�
3 S' �'ei -// / N .` 4 t 3/f i 15 W �';���//?'' ` D^Z" 2C>
6.Is(are)the well(s): C7Permanent or ❑Temporary
S' ture of erti ed Wel CI ont actor 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 L'1No 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: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16 (ft.)
For multiple wells list all depths tfdifferent(example-3Qa200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
7 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"+"
11.Borehole diameter: 6 (1n,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota 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)
Z Method of test
S 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