GW1--06120_Well Construction - GW1_20241014

• WELL CONSTRUCTION-RECORD (GW-11 For Internal Use Only: i
1.Well Contractor Information: -
3 On n Lu Y-e. .H-b\PJ ClieY
••14..WATERZONES '�-#;�,-.•-'--,�
Well Contractor Name . FROM TO DESCRIPTION! �.7.
ii-Us5 go ft 2.ft q�' . Isp,„i.
f. ft
NC Well Contractor CertificationNumber ;:15:•OUTP:it:CASING'(fot ini-ciuTt dk."v-elli)oRMINER(i1.6p"licable).:: `-:
Morgan Well & Pump, INC FROM TO DIAMETER' THICKNESS MATERIAL
1 ft. pi ft 61/8 IA. SDR21 PVC
CompanyCompany Name -lb.-INNER CASING•OR TUBING(geothermiil cliffs"ed Too a 3 3P) •-:
2.Well Construction Permit#: , / FROM To DIAMETER THICKNESS MA .L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
-
3.•WellUse(checkwelluse): • ft ft. in -
Water Supply Well: %171 SCREEN °:.•- -:•. 'c''i .:.•-• ::.r%-„-ir.:.:::.k 2: -: -:- •
FROM TO DIAMEFER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural . ❑M��unicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) E esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) l 18;GROUT. : :' LL "
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:. 0 f• 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation �. .`;:_ >c :•::,:', "
:
.o19.:SAND/GRAVEL`YACK(ifapplicable)'> - :'c=`-::• -iG_zr:c:-. �
❑Aquifer Storage and Recovery ❑Salinity Basher FROM To MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
N ❑Geothermal(Closed Loop) OTracer 12D:DRTLLINGLOG(atisc'}iadaititintdahieta'ifrieceasary)•i;ir i'-�`-a?`.:; ; !1? •
❑Geothermal(Heating/Cooling Retum) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
4.Date Well(s)Completed: 7. i _Z- Well 1D# 33 ft Qg0 R' 6jY,i•� 6v+K.n-t
5a.Well Location: l ft ft • J S -C.;,L,� r ' i i
1 P � L C ft. ft {} T,,.y+u ...,
Facility/OwnerNamee D Facility ID#(if applicable) - r ft. ft Ur I 1 1i_ 2024
�L.� J k'k51J • !®ll^'� �i/� Iv'�1VY` e� /I/ ft ft . . !f`c:,.,,. ,t:-.. ,-. I S
s
Physical Address,City,and Zip �� R ft 'y.t•�' 'wt
ROB r q 1:21:u1+MARKcw if.: -:Si;;-Wi;.,:::
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:
3S, So70-q N —fo, 736 1 d 6 W - q-2.5 29
the well(s): e e t S• tors of ' ed We C1I ontractor Date
6.Is(are) InP rman n or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is thjs a repair to an existing well: DYes or I]No ISA NCAC 02C.0100 or ISA 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: ' �(r' 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: 7 vv (ft)
For multiple wells list all depths ifdyferent(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
4/0 29a. For All Wells: Original foal]. to Division of Water Resources (DWR),
10.Static water level below top of casing: (R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater 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: roia'.7 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 GPO:Copy to DWR,CCPCUA
13a.Yield(gpm) ,
S. Method of test: pressure air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorineAmount:
FormGW-1 North Carolina De artmentofEnvironmental QualityDivision of Water Resources !
P - Revised 6-6-2018
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