GW1--06121_Well Construction - GW1_20241014

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information:\)o'nn 1,u le-e. _ •
,.14..WATERZONES "psi: :: ....:I'..i:'r . .. .• ,
FROM TO DESCRIPTION I
Well Contractor Name 1�'y it ��3 ft. - 2 jy�
ik. QS5,A .
ft ft
NC Well Contractor Certification Number ':15:"OUTER CASING(for•multi-ca.+'ed`lvelli)"ORLINER(if:dp""lichble)r;•.. -
'rt
Morgan Well & Pump, INC FROM TO DIAMETER'' , THICKNESS MATERIAL _
1 ft j jy ft. 6 1/8 fl,' SDR21 PVC
Company Name
4 va 3 0 •.16:INNER CASING.OR TUBING(geothermal ibil'et1 loop)i:"••`i''d..
2.Well Construction Permit#: G 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. M.
1,17:•SCREEN :•••.': •.-:i'I..._ :•b-.rei 1;117i-=•'.::3':,!,-:`.:. • .•• ',. -•- .
Water Supply Well: FROM TO • DIAMETER , SLOT SIZE THICICRESS MATERIAL -
❑Agricultural ❑M�unicipal/Public it ft. in.
❑Geothermal(Heating/Cooling supply) la�Residential Water Supply(single) ft - ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1;18:GROUT.: ::_ ;.;> .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 R' 20 ft bentonite poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19::SA'ND/GRAVEL'TACK'(Ifapplicable)'.• ' i.,S •..••,.r:•:;4••:..1.i .ii'r:
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. R. '
❑Geothermal(Closed Loop) OTracer :'20.1DRILLINGLOG(attach irdaltional'shied if necessary):l;_ ?u as'.i. 'X?.
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type grain size etc.)
d 0 ft ZI ft gel- 0pi..
• 4.Date Well(s)Completed: / ��24 Well DM 22- ft' WO ft 6 6a^K.tt
5a.Well
Location: /,� . ft ft f ,.
e 414� "&ifet.✓Ib9 ft. ft. C..' _ > . r n�-._'
Facility/Owner Name / Facility ID#(if applicable) ft ft .r 1'.'O OCT
6
�
V zS ve,--- Ga u'4.[y h hi__ v5hlls6,// A/C ft ft. .. 4 Z024
Physical Address,City,and Zip / /// ft ft
/-_WAY _ 6 $-21112EMAIIK .T1 .;-.1i 3�.. , - i.,tiid`:5,5:C:.p v rl.i::''
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 1 22.Certification: -
3$ 6'625 - N --V., 335-WV/ We-
6.Is(are)the well(s): InPermanent or ❑Temporary
Slife,"1-71%0P*".
ontractor I Date
By signing this form,I hereby cerhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PJNo 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: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2eC) (ft.)
For multiple wells list all depths if dii ferent(eiample-3@200'and 2®100') Submit this GW-1 within 30 days of well completion per the following:
ff�� 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
10.Static water level below top of casing: Ye (ft.) Information Processing Unit,1617 MSC,,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in)
Program,1636 MSC,Raleigh,NC 27699/1636
12.Well construction method: rotary 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 i f 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) I i Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: granulated chlorine Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018