GW1--05429_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J 0 Y)n Lu Y e �'t7 J I�/
14.WATER ZONES ` ,
Well Contractor Name FROM TO DESCRIPTION
qI S5A 120 n- 12I ft. _ 101p,-,
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased:well)OR LINER(if ap licable)
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATRRIA_L -
1 ft. LtQ ft• 61/8 in' SDR21 PVC
Company Name Q/� /yy 16.INNER CASING OR TUBING(geothermal closed-loop)
J
2.Well Construction Permit#: 3 [ ZJ t/41 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft in.
-
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MM/unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Gi esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: CSI ft' 4e It. boiiWailift -mod
DMonitoring ❑Recovery vi ft. Y0 ft- A/ i p Grad-
Injection Well: 1
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer 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) .. -7 .
FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) )t❑Other(explain under#21 Remarks) O ft. j O ft' y,C 1 �`.
$`23`z7 ft. ft �C fq f.: t
4.Date Well(s)Completed: Well ID# Z� G`/ (j✓w11 �-- --
5a.Well Location: N ft / t ` ♦ ./ f
j7ref1 ' A71 yi(l ft. ft.
-- SEP 05 2024
Facility/Owner N'ame,q Facility ID#(if applicable)
yl/�S O AA de / l;cA foil-- it/G ft. ft. ,i.:,,.. . "•-.:r, -.;,1.;r4
ft ft. i .'. '_
Physical Address,City,and Zip ,J
5 f�4 Jy g/3 y {21.REMARKS
County Parcel IIdentification No.(PIN)
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
35. v5/3 773 N --Y . 27397,69 W �,,v�
S' lure of erti efi d We
6.Is(are)the well(s): lPermanent or ❑Temporary
l CI ontractor Date
By signing this form,I hereby cerh,fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or PJNo 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: Zed (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)
yC7 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"+"
II.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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) /© 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