GW1--06118_Well Construction - GW1_20241014

I
.` WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:3o\' n LU \ - 1i-b‘m y 1:•.:'::° .". ... .. - ....w <
Well Contractor Name FROM TO DESCRIPTION I
qUS5,A . h ft
NC Well Contractor Certification Number ',15.1ODTER CASING(for'iiiiiIti-caae'd�welle).',ORLINTER•(tf ip•livable)Z:: '..I;;!...
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft i g ft. 61/8 • SDR21 PVC
Company Name �•S t�c� �j J :16.1NNERCASING.ORTQBING(geotbermidclosed7oop):::- -.._.'.: ..>r:..
2.Well Construction Permit#: 4., 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: i17:SCREENi'�-•.: :t -' :;.11:1s'it:':•:a` 'id:. • .•`tl'; .••-. -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M��unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Cr7Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) 3;18:GROIIT.;: :‘.: :'.;,= '•: '._:.,: ;:?>;,':,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft bentonite poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
7:19:iSAND/GRAV.EL.PACK'(ifapplicable) s • ' .11=- r:,-.:.4:-.41-,;,ci=i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
0 Geothermal(Closed Loop) ❑Tracer :2DDRILLING-L0G(attachadditidriil Weal(ifne&ssiijr)" :17V.' `',:.-Y' '•
OGeothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillreek type,grain size,etc)
_ Oft. 2g lied- >' A-1-
• 4.Date Well(s)Completed: /q`)Z' 1 Well ID# 2.9 t VOC) ft 6:--7 6,-.. -t
5a.Well Location: p a�((����.yi /
Re tll. v jaise1 j2�t�+J 9 Ci� ft. ft. • 4 •; ' ,.
Facility/Owner Name Facility ID#(if applicable) ft ft n('4
j, �l<5 R�'2 d e Gd R eiI Al ft. ft. t, r a24
Physical Address,City,and Zip ft. ft i. r?
&Ili'-{ • 1-21 REMARKS .,. .... ..' '. .. _ ';1:_'lA.S- t<`ZIV::_ i('.FR
County Parcel IdentificationNo.(PIN) i
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35a 01701 N --��, Sd`1 '� W �r�50" 7-1Z-29
6.Is(are)the well(s): dPermanent or ❑Temporary
S• ture of e ' ed We CII ontractor Date
•
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or dNo 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
9.Total well depth below land surface: P0 (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 2Q100') i
(� 24a. For All Wells: Original form,to Division of Water Resources (DWR),
10.Static water level below top of casing: -f d (ft) Information Processing Unit, MSC;Raleigh,NC 27699-1617
If water level is above casing;use"+" 1
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'1 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) 6 Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018