GW1--05422_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
///C\o�nttractorInformation:
P 'J`' 1 'y!
3 t ,fl W L . -�i/ V V i` FROMATER DESCRIPTION TO
Well Contractor Name Q 6 ft. 'a, ft. (�{�npJ✓j
li-��` JA ft. ft. D
NC Well Contractor Certification Number ;:15/OUTER.CASING(for'mbiticased wells):ORMINER'(if a i liceble)' ::.._`
,.- .
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. Ct ft. 61/8 '°• SDR21 PVC
Company Name f� �] ..16'INNER CASING OR TUBING(geothermaldo"sed-10 ;`_:x ',?>:r'':
2.Well Construction Permit#: "1 U 1 a 3 FROM TO DIAMETER — THICKNESS — MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft• ft. m'_
3.Well Use(check well use): • ft• ft. in.
417:SCREEN,.. .. . ...,. Fro ...t ._ '!•,:tSz.,`...t.P:`` :`. ,. ... .
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) '18;:GROUT:.: ..):? ,:,. ; = _ _ ..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite _poured
[Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
—
'_19:=SAND/GRAVEL PACK'(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
El Geothermal(Closed Loop) ❑Tracer 20 DRILLINGLOG(attaclf additionaliheetsifrieeesasry)^:,":.5,�'•.-:: r
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ' FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
o f- 3C/ ft. gek 'II rrt-
4.Date Well(s)Completed: 0- 7'31 Well ID# 3 I ft- ft. G r, G +
ft. ft. J
5a.Well Location:
Eitj4)1 f3d)la/1 ft. ft. "' __
-Facility/Owner Name Facility ID#(if applicable) ft. ft. ` `� ;�1+ .
/Q1 Ai,e v1 cW Gird€. It✓ry A)C ft. ft. S E P 0 5 2024
6�r� ft ft.
Physical Address,City,and Zip 3 _ •
W (2' RF.MARICR i .,- iC:�:7.:..,.(',: i,.
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 739q z97 N 'qo. qe473 2 7`l w 7.-30f-Z?/
6.Is(are)the well(s): OPermanent 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: DYes 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
9.Total well depth below land surface: 2.4) (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: �� (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(TIC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota'.7 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) 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