GW1--06512_Well Construction - GW1_20241104

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- 4' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: - I •
jO\ n Lu 14-e 1-1i-7\NJ C l( 1
Well Contractor Name FROM TO DESCRIPTION i
us . 310' 312- 50119P11
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NC Well Contractor Certification Number ;:15:'OIITERTCASING'(fer riiulfi-caeeavillas):ORIdNER(if.i6 licbb1e)=t.. '_- _
Morgan Well & Pump, INC A'V/+ FROM TO DIAMETER ' THICKNESS MATERIAL
1 ft- 7C ft. 61/8 tn• SDR21 PVC
Company Name
(� 16:TNNERCASING,OR TUBING(ge'othermil'cliia"ed7oop)_: ;z.».-`i,;
2.Well Construction Permit#: 3�I C 7 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 in.
Water Supply Well: 117:"SCREEN'_-' • '...e i •:.• in-::_.rti •: e
:1:- r.:._ . . - :::•::::1:':•-. •. •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural o� �MM�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [a�Residential Water Supply(single) ft ft. in. •
❑lndustrial/Commercial ❑Residential Water Supply(shared) iaScGROUT.:4,:-: " ''0
❑Irrigation ❑Wells>100,000GPD 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)Zemediation 119.:SANDIGRAWIIPACK'(ifipplicible)• - 4" ' 'TY.W.."". '
❑Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL , EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft. ft. •
❑Experimental Technology DSubsidence Control ft. ft. •
❑Geothermal(Closed Loop) ❑Tracer ::.2O DRMLING LOg(Waal additionfil eheeta if lien.iiiry) :=£ ",- .;.' ';; s.4 •
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION�y (color,hardness,soil/rock type grain size etc.)O ft t g ft. I�Gd-- 0,4.
• 4.Date Well(s)Completed: 16--3-Z�/ Well MO 11 ft 3ZOft. �„� _I,
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5a.Well Location: ft. •
4 IN)i kA)-off-- !"nn 0? �l LS ft . ft. T
Facili /OwnerName Facility ID# if a licable ft ft.
26d l e,i9/1 S el ICw►n 4,d1►5 nIG ft ft. NOV ; u 2094
PhysicalA,ddrreesss,,City,and Zip ft ft.
&NV-c `. z 954 ctc3 8's-21:REMARKS:- . •'i.i:...._. ... . ....'.I ...-. ;f:i.;'0 t0,' u':a. y'A
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County Parcel Identification No.(PIN) fy:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) L 22.Certification: .
3 5, sz/V 220 N ' -gd� 6517ill0 W )0-3�-0.
6.Is are the wells: InPermanent or ❑Tem orary S' tore of e ' erh�d Wel Contractor Date
Is(are) O P
By signing this form,Thereby certify that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or In No 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.
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drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 2-v (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2@100)
7V 24a. For All Wells: Original form to;Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" -
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
rotary 1
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 of the county where installed
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FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Method of test:
�P` air pressure Permit Program,1611 MSC,Raleigh,NC 2 I699-1611
13a.Yield(gpm) e.
granulated chlorine
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018