GW1--06117_Well Construction - GW1_20241014

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
3O'nn LU I-e 1-i-b W aiCA( '
-.14..WATER ZONES ..p'wi'::% '. .I.,o'..:'e .'. •r:
FROM ,
Well Contractor Name M D
�S 5,A .,,,�zt TO DESCRIPTION!
zit 3 tt• _ 3/rm.'
ft. ft.
NC Well Contractor Certification Number 415.1O1:1TER CASING(for iiiiiltizeliiidiwelli)'ORiINER(rf.ap"lcable) :.) .
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft• )(t ft. 6 1/8 in. SDR21 PVC
Company Name 3(9 GV L 1
! •16::INNER CASING:OR TUBING(geotheimid'clo`sedfoop) :..•:r ,.:=.•';'.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 1,171SCREEN _.:... - • .: ' '.•_ •'•:.cisi.*:??=:••::•,;r:7:. :•;:.•;.`..a.•::.
FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18:.GROUT.v:;: '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 R• 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:a19::SAND/GRAVEL"PACK(if applicable)'l •: -'' : ....!,' %: •i=r xs'7,<;"'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
ID Geothermal(Closed Loop) El Tracer A0:DRILLINGL( (a'ttacli idditioriai'shietdif iieceaiaiy)r?.<.::Fes:;, 1 -r 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soillrock type grain size,etc.)
9^IoVZ b ft' .Zl ft. Ped— P2/r*
• 4.Date Well(s)Completed: 9 Well ID# '-/ ft. // ft e-dwi. swt
5a.Well Location: JOe) ft "? ft. O I,�,� G ,
v ko& G 3 v111�44 �'1 ft. c� '""% i �• `-,
Facility/Owner Name Facility lD#(if applicable) l R ft l Uf T 1 4 ;n24
vi1 ft. ft. `t
Physical Address,City,and Zip ft. ft C ; • 'i
County 'Y'`✓ •
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well
3 Sd s''1 1992,,one lat/long is 9 t) go c N .?-�O 1 l ! 22.Certification:
GJ � S C/ 9
6.Is(are)the well(s): Permanent or ❑Temporary S' tore of erti ed We Contractor Date
By signing this form,I hereby cert Jy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes 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: 1 24.SUBMITTAL INSTRUCTIONS •
c/
9.Total well depth below land surface: 419 (D) 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@a 100')
`Z p ft 24a. For All Wells: Original form lito 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 casin&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: rota'.7 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
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 39P Method of test: ; ,
•
granulated chlorine
13b.Disinfection type: _, Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018