GW1--06489_Well Construction - GW1_20241104

I
• " WELL CONSTRUCTION RECORD (GW 1' For Internal Use Only: 1 "
1.Well Contractor Information: - •
3Ofln l u \te- I-?'Nl l/ _ _ ..•. .
,14.,WATERZONES .:e •'-•,a
Well ContractorName FROM TO DESCRIPTION I
L- .9S5.A ,zl ft i ztft. 30 yp
ft ft
NC Well Contractor Certification Number 1:15:OUTER:CASING'(ior multii ai kktivelli):ORMINER(if.ap"licableP::: ,:;.,..i,...
Morgan Well & Pump, I N C FROM TO DIAMETER ; THICKNESS MATERIAL
1 ft 1$ ft 61/8 "• SDR21 PVC
Company Name
t J` 17 el tJ '•16:IIQ1�R CASING.OR TUBING(geothermk closed-loop)'1-•••i= -r
2.Well Construction Permit#: -(1 I FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. m.
3.•Well Use(check well use): • g ft ft. in.
Eir ft.
:-5•:p :•.riti.,: ;--.,:.:.:a;.,•ri - -.:.••-,-_.
Water Supply Well: ='
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural o��MM�unicipallPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) lac'Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I:18::GROUT.;`.:: . - _ . . .:E`;;;•.s•�,•'�",_;,•.•.---‘•;
❑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
❑AquiferRechazge ❑GroundwaterRemediation i19:SAND/GRA..EL`PACK'(iifapplicable)'E. '+ �t=::':_. .1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
-, ❑Geothermal(Closed Loop) ❑Tracer :1s.20.DRILLINGLOG(etfaccliaddftionidehee&if'tierrasai• ;,iWs.M.-;;s-f? ;Te •
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) y� L
4.Date Well(s)Completed:/d O Zt Well ID# • ,3 2 n' J e 6j1-ay 6e-4.4-t
•
5a.Well Location: R l r" ' •-- - -
/��.+/j _?e 9 LC( ft , ft. ' _.4_-.i 4,. - ° i `e - '•,
Facility/Owner Name Facility ID#(if applicable) ft ft. �
5.z9 sit;, 7L I ot iiv-)' *D-- 1.�- ,NG ft. ft. No / [G2-i
Physical Address,City,and Zip ft ft I r ,•,;.-:. 1 '"r, o-
Rn� a Q�• r r
e l✓i/l. ;VOA "-.1415 :21:RF.MARICR!" .!.vki:..-,_.. .r... ...-a:aTc ?':tit:':;"-V..riF.. ... , •
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:
✓5. 66 7"d N -'g0.. 36og3 W /i f®--�`-2.tt
6.Is(are)the well(s): nPermanent or ❑Temporary
S' tare of a eCI ontractor Date
. 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 l 1No 15ANCAC 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: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /�g (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 2Qa 100')
d f 24a. For All Wells: Original form to Division of Water Resources (DWR),
7 t
10.Static water level below top of casing: 7 ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"4."
Il.Borehole diameter: 6 (in) 24b.For Injection Wells: Copy to DWR Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary 24c.For Water Supply and Open-Loop Geothermal Return Welts: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) e Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated chlorine 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018