GW1--05423_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
•
1.Well
Contractor Information: `- 1
J
30nn w V-e, h-1 7 V
FROM TO DESCRIPTION
Well Contli-'raccttorrName
�/) ft. O 2 ft. �� p�
�L� V ` J. OO+ ft. 11 ft. r
NC Well Contractor Certification Number i15:'OUTER.CASING(for'mulfl=b1ied*Rh):ORIIlNER iit• • licable)`?: •
Morgan Well & Pump, I N C FROM TO DIAMETER —THICKNESS MATERIAL
1 ft 7S f• 61/8 in' SDR21 PVC
Company Name Y)"f L AG:INNER :.1,>"! :::'''':
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft' ft. in.
ft. ft. in.
3.Well Use(check well use): •
417cSCREENii. .... . _.. _^ �sr..;;`.:.3 _._ A:7-:---•r~
Water Supply Well: FROM TO DIAMETER SLOT SI THICKNESS ZE MATrmrer.
❑Agricultural ❑Municipal/Public ft. ft. b3•
❑Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18f:GROUT:::t` _i-t=:-=-<<•;:'..; ., - ..
❑Irrigation ❑Wells>100,000.GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 f• bentonite poured
❑Monitoring ❑Recovery ft ft•
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if aphcabIe)
17Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑A 4urfer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :'_20:DRILLINGLOG(ittieliFdditional eheiliifrieceaIkr)1r`,.5,-'s✓: ,:�=r:
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) v ft 3 g ft. ge) 1 1 r-�
4.Date Well(s)Completed:Q tc-2y Well DO 3 q 64// ft. p.vvvi K.
5a.Well Location: 65 ft '6s ft- 6},s,1� gi 'A le
.1 C_ C
cc_ ft ft. /
-Facility/Owner Name Facility ID#(if applicable) ft ft' ' `/�"'+ �y 1"�
96Z1 5)#Ke5 F''47 kd- St.ItSZvk% NC ft ft SEP 0 9 2p2�
f. ft.
Physical Address,City,and Zip Ir'F -
r215RE1KARKSt �_''' ==."�a.��: '.i:-"�':� ^3f+c; "la.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/l'oJng is sufficient) / 22.Certification: I
3s, S77N/b� N —gd. 3ZC�ybo W g/5- -2Y
6.Is(are)the well(s): inPermanent or OTemporary Si e 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 l 1No 1SA NCAC 02C.0100 or 1SA 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@l00)
��// 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `7° (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: rotary 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) 430 Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018