GW1--05433_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. llll Contractor Information:
Ptak 61 se 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1 JS) ,A izo ft. 1i1 ft. A
'rjv 1w�/y/'1 �tf./ ft. 1 ft. Ad
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
Company 1 ft' /iit ft' 6 1/8 in' SDR21 PVC
P y Name
2.Well Construction Permit#: tAJp-
a Li -'-1 D- 16.INNER CASIN OR TUBING(geotherptalrcloied-loop)'
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 I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ' LaliCesidential Water Supply(single) ft f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ['Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff. 20 ft bentonite poured
['Monitoring ❑Recovery 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
❑Aquifer Test ❑Stormwater Drainage ft- ft•
❑Experimental Technology ['Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
-
4.Date Well(s)Completed: D'5^�`'7 Well ID# 2/tlft. O3CI ft. I v.�(J�\(2.4chc_
5_ Well Location:
�c '2 G1 ft #110 ftk66310 4_ ( (era Vf
' I CO( L S �s�l4 ft. ft. "V- �G
Facility/Owner Name Facility ID#(if applicable) ft ft. r- 77.
LagZ g atl 4i ilt Pedi• ft. ft.
Physical Address,City,and Zip /�s� �/� ft R h-,
I ,n'o 0(_ O16 O/ d? 21.REMARKS
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:
3Lj . 3te31 N F- • 707lele Wde-4. ---- /--z--.-- k /‘,a f
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: ❑Yes or ONo 15A 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: ' Il 24.SUBMITTAL INSTRUCTIONS
1,•
9.Total well depth below land surface: , ', .,, as (ft.)
For multiple wells list all depths if different(example-3 a00'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
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"+"
11.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 ,d Z.
13b.Disinfection type: Amount: el/
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018