GW1--05420_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _
`) O'fln Lu Ye, P`t7 FROM TO ATER ZONES DESCRIPTION ,•
Well Contractor Name 1 62 ft. G3 ft. jd!/hp
ii-ucJA gs ft. 6 ft
NC Well Contractor Certification Number 1;15IOUTERTCASING(for iiihlti=cue wd' eIls):OR1NEROfi" lie'ble)' ".,::,:=•.
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft' 5'2., ft• 61/8 in• SDR21 PVC
Company Name Uof s-coI
16:INNER CASING:OR TQBING"(geothermal clo"sed=low):zr;.';:'',-„r':"•':,'
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.
ft ft. in.
Well Use(check well use):
4;17ISCREENM,;1.; :::e.«aL'=3 y'i. i i-;.;;Wi-;t•:•.iFr.` 4:`•:;': [:i :':i:.,•:-:..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) :118:GROUT::"y'' �" .. ::'�� •fr:_-`. - _;c�0-:'::•;,-a:l.;:_;, .
❑lrrrigation ❑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
'_19r.SAND/GRAVEL'PACK'cif'applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barber FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `.'r20 DRJLLINGLOG(attac}iadtitional sheets ifiieceaeary)'.5'.' .1":;, ::, „::3;;=
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type grain size etc.)
G ft' '6 ft- IeeJ- J-k-i-
4.Date Well(s)Completed: (S-Z, Well ID# j 7 ft ills ft 611
6,4.41-
ft f.
5a.Well Location:
1S5 c'-/'i it.L a-C ft ft. g ' r': fc.- .
ft. ft
-Facility/Owner Name Facility ID#(if applicable)
j3)0 cofG�k-c tilt/ ''`, li�'y C.1G MI it ft SEP 0 9 2024
Physical Address,City,and Zip ft ft If ::.f. .t r'"'^2.r-o -.1 u1q
t'l esiv•Al zO Ao 7 k21 RRMARKC'. _ :3:.. .i:=.-..•.. • • L.u.`. fli,:-.
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:
3s. ells 937 N —S'o, 6/0909Z W S"SZy
6.Is(are)the well(s): inPermanent or ❑Temporary Signature of Certified 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 Et No 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: j s (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 a@100)
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tie (ft.) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
624b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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
(ie.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
Z
S 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