GW1--05419_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor\(nt' Inlfor�maation:P `, I
J 1 ,1 ' IN1 -e, F,i� V i a IGt( ..14FR WATER ZONES "M TO DESCRIPTION::'• . . . ... - .. . _
Well Contractor Name
1 ame G 7 ft. 6 J7 ft �i O T
ft ft p
L\ pSE -
NC Well Contractor Certification Number ;15:1OUTER CASING(for'multi-Tieed wells).OR L1N R(if i llcabley ::,: ,_ ,
Morgan Well & Pump, I N C FROM TO DIAMETER - THICKNESS MATERIAL
1 ft 5 D ft• 6 1/8 in. SDR21 PVC
Company Name o/9 q c .16:'INNERCASING:ORTUBING-(geotliermalclo"i'ed=10 I;:.-_ 5_;::'?'_ .
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): • ft ft. in.
171.SCREEN:` :,;:' '::,"rF L=r c '`"�.;ts,} z F;;'•.n-P.::'..'y:`:;'.:, t"•:':.;-.'' .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) jl6sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -.18i-,GROUT::;;;;` ?r- '':,ii... :.° .--
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 fL bentonite poured
DMonitoring ❑Recovery ft ft.
Injection Well: ft ft -
❑Aquifer Recharge ❑Groundwater Remediation -
.'1:19::SAND/GRAV.EL PACK'(iif'applicable) .
['Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft' B
❑Experimental Technology ['Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer _20:DRII.1,INGLOG(attachs'dditiina sbeeilifiieceaiary)'Ii=.",'. ,�:::;:
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain srzr etc.)
p ft. 2.6 ft Red.. j!r'
4.Date Well(s)Completed:?-7-Zi] Well ID# 1-7 ft I jS ft 6,-'f er-44,4
ft f.
5a.Welle Location:
B4,4_,A10/0- 11 u
66/ ,0:!) ft ft "•_, I- ti;/
Facility/Owner Name Facility ID#(if applicable)
INis cd a-94 4r OP- 50.I1s > :NC z0N7 ft ft SEP 0 5 2024
Physical Address,City,and Zip /]�/) ft B if,[_-T-<i. ` r•.";I -u UA.o
e�W A 201.v D/ r21 REMARIMI' _. •t>,-1=-`ni'1'.5 -.-....v: .. :
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.Certification: -7
7_5.d/z4e0/ N -0. 6C) 9O�3 W ‘- / ray
6.Is(are)the well(s): I lPermanent or ['TemporarySignature of edified 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 L'JNo 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: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i 11 (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')
L f d 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) 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: ro+`a'1 Y 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
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ?� Method of test:
granulated chlorine
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018