GW1--06042_Well Construction - GW1_20241011

'` WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Well Contractor Information: - `' ' �/•
•
OY n 1 \Le, li-7 a-1-e 1
Well Contractor Name FROM TO DESCRIPTnONI
` l��J fz3 30YRM .
:,....
NC Well Contractor Certification Number ,:15:ODTERTCASING'(foi'iifulti-caiea,:%relliyORI:INER(if.ipi licabie)z:: ;:1)-..
r,:- . Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
� i. 1 ft 90 ft 61/8 in. SDR21 PVC
`43 "'Company Name /a
< A �2 �Ot,(�, 16:IlVNERCASING.ORTUBING eothermsdclos"ed=Ioo _ , . -
•2.Well Construction Permit#: ClI ``w �•[J ((Www FROM TO . DIAMETER THICKNESS) MATERIAL'
.'1,,,.`•� List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
i ,r-' 3.-Well Use(check well use): • ft ft. in.
WaterSupplyWell: ¢;17i•SCREEN'. .'--. 5''i.:.•- : .r::i'n--::•.:3'...Y`.: • .' ::.:':.::_:••. . •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑M��unicipal/Public ft ft. in.
['Geothermal(Heating/Cooling Supply) ll}iZesidential Water Supply(single) it ft. in. .' ?''r'
❑Industrial/Commercial DResidential Water Supply(shared)
1;18t:GROUT_:.. _ . .:E; ...,,yg, .. • _.r.;ram. i
:.
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACE&IENT METHOD&AMOIINT:-. ?'w•:;
Non-Water Supply Well: 0 ft' 20 ft bentonite poured .':? i :-..
['Monitoring DRecovery ft. ft. .
Injection Well: - '' .-
DAquifer Recharge ❑GroundwaterRemediation ft. ft
119.:SANDIGRAV.EL`PACK'(if applicable)'> '•. . s-_.r: ,-,i"::•:l;:c 3�• .,,
❑Aquifer Storage and Recovery ❑SalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD . - - ? •4
DAquifer Test ❑StormwaterDrainage it ft. . :-,..-,....?„&,,
❑Experimental Technology ['Subsidence Control ft. ft. • - • -"'r
'• ir'-
-, ['Geothermal(Closed Loop) ❑Tracer 20::DRILLINGLOG(attachiddifidnel heetaifrieceasaiy);ii` 't-`_".•-:.'gig';!Y�?
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21Remarks) FROM To DESCRIPTION(color,hardness,snivroektype'gram size,eta)
p ft j ft. Jed- 1rt :;;;.:,,,• ,
• 4.Date Well(s)Completed: !`"3d-Z( Well ED# !C R' J 5 ft. 6jy�y 6",4.1
ft ft
5a.Well Location:
� a / A 1)(dn
ft ft. r.. - i,
Facility/OwnerName FacilitylD#(if applicable) ft. ft.
ST/5 AleXe44k rdQ- CC rk- l/, ft ft. OCT 1 1 ZU14 ..
Physical Address,City,and Zip H• ft _ 1..,,,:',_ .
i:21:R I2K FMA4w `Y.:: -'lkt.yt..w:._, • -.x;:;.i.,.•.k;...: ;,c-
County . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification: •
35, '11'9z2a N -go, 72,573 W 61_3d-2.51
S' ture of a ed We Contractor Date
6.Is(are)thewell(s): C]Permanent or ❑Temporary
. By signing this form,I hereby certi;&that the well(s)was(were)constructed in accordance with •
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or 154NC.AC 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
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: + ii l�/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J 'S (ft.) Submit this GW-1 within 30 days of well completionper the following:
. For multiple wells list all depths ifdifferent(example-3@200'and 2@100') y P
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: I/0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(MC)11.Borehole diameter: 6 On)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ro La'l 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
13a.Yield(gpm) Ye Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine
13b.Disinfection type: -Amount: I
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018