GW1--06045_Well Construction - GW1_20241011

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information: 1 •
. \) Om W' - . 1--'-b VV ii 1.4..WATERZONES• ..`�4s-.._-.^.. '_.::!:..; . . - . .. ..
Well Contractor Name FROM TO DESCRIPTIONI
� .S5 1/6 ,ft lizzft• 35PAL
ft. ft.
NC Well Contractor Certification Number •;15.'OUTER:CASING(for multifersedtwelle)'ORI;INER'(tf.ap'licable).'h.: -= -.
Morgan Well & Pump, I N C FROM To DIAMETER THICKNESS MATERIAL
1 ft /10 ft. 61/8 in' SDR21 JPVC
Company Name
,HA- w E. 2_60,_ coo 6 .16.1 NER CASINGGR TUBING(ge'othernill"eltac loop)fr. %i:{�.. "'=:
2.Well Construction Permit#: 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: .17i SCREEN .`= ..:: :.:a , ' •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑M��unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) I1 esidential Water Supply(single) ft ft in.
❑Industrial/Conmrercial ❑Residential Water Supply(shared) 1;18:;GROUT.:• :. .. :C: ,T•*::: . :•is =,;: ;::; :.,,:
❑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`YACK(if ipplicable)': . . ." s-_'.�,.:..l:-._=,'<;:=•+.Tn;:,:.�-
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) OTracer 1:20:;DR1LL•INGLOG(attacili'i daitioni l'sbeets ifnecessary)1 i:: is"g??''. ;:;e
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size etc.)
o ft 2C ft Iced- Ori-
4.Date Well(s)Completed: # 61415-Z� Well ID# 2_7 ft. Clgi ft eMl�,i S<ti�
5a./Well Location: L Cj'Y G ft go ft yb / ' 6 A-
aL i/4 6/0- .Y�M'/tGs l is ft. ft •
� . , . .�
Facility/Owner Names Facility ID ft ft. • ro �n-
#(if applicable) �/ . Y' ' E_.ii.
-4 e . . j�q i ;r'
<C d .RJ'ie` 1/4- t��IC/1Y� C. ZCOLS ft ft OCTPhysical Address,City,and Zip ft ft. I 1 ` 2024
"t. 5 - ;._-.. - ....,m. . .. - S;-izc.,_'- - ..
County Parcel Identification No.(PIN) D J••c'%'-0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
s; 19/9d25 N -got t9790'S3Z W �P0 31' g-/Zy2g
S. ture of erti efi d We Contractor ontractor Date
6.Is(are)the well(s): ClPermanent or ❑Temporary .
. 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 nNo ISA NCAC 02C.0100 or 15ANCAC 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.
dulled' ' ,l 24.SUBMTTTA.L INSTRUCTIONS
/)(Jv 9.Total well depth below land surface: Y p at.) Submit this GW-1 within 30 d days of well completion per the following:
if For multiple wells list all depths erent(example-3@200'and 2@100')
(�v
(ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / ) 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 t 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 overl100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 3 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