HomeMy WebLinkAboutGW1--06515_Well Construction - GW1_20241104 1I
- "' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:30"nn Lu lLe. \-i-b w (
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'14...WATER ZONES '44, ...:f.:J-:Y.
7.
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FROM TO DESCRIPTION !
Well Contractor Name
.A 2146ft 2H3 ft �yP -
NC Well Contractor CertificationNumber 15:OUTERTCASING-(for multi-caaedSvelli):ORI,INER(if.up"licable) : ::;j:-
Morgan Well & Pump, I N C FROM TO DIAMETER i THICKNESS MATERIAL
1 ft cZ ft 61/8 in. SDR21 PVC •
Company Name l 6y 5 -
oaI% 16:AVPIER CASING.OR TUBING(geothermsd"closed loop) _:.-`;,;
2.Well Construction Permit#: 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.
2;171 SCREEN;'"`-:•`:". -.-:'c•'i :-.f�;: Pi`; 1.,.,I'-.'2.` • _.;.••..--.
Water Supply Well: -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural �:�M�//unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Ca7Residential Water Supply(single) ft ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) j.1S:GROIIT :�_ :•K~•i:w ,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL F,MPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft bentonite poured
❑Monitoring ❑Recovery ft ft.
Injection Well: ,
it ft.
❑Aquifer Recharge ❑GroundwaterRemediation �:^,� a
.i19.:SAND/GRAVEL`.PACK•(iifipplicable)'> -. s-;:-: ,;;^:::•i;r:_ *:-, -::::.�f
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft
DExperimental Technology DSubsidence Control ft. ft.
_, ❑Geothermal(Closed Loop) OTracer 5:20:DRILLINGLO'G(attach i ddifioni l shehta if neceasaiyMM:V_x `.VP;i V` •
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain eke etc.)
['Geothermal
ft 2g ' Iced- i i-i-
' 4.Date Well(s)Completed:: 0 �'�� Wel1ID# 2.q ft '3 cfe ft 6.- 6,+'s,. ti r " ;—%--- _,
5a.Well Location: ft ft
'APY4- t4Ay Noyes Lc- ft. , ft. i , • NOV t)
2'1124
Facility/Owner Name Facility ID#(if applicable) ft
i- l ft ft. i,`-" .,: ,. erg;i;.r.At
Physical Address,City,and Zip ft' ft'
e lJa1 • 1:21: EMauxc; • .;-t:: . ...`::PS- ,,Mti;a•' __ ...... .
County Parcel IdentificationNo.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat�n sufficient) T� 22.Certification: •
35, �—I 7 1 N -0, 03 W - ..-......d. ./1117501. iv-9-2LJ
6.Is(are)the well(s): nPermanent or ❑Temporary
S' ture of rti ed We CII ontractor Date
By signing this form,Thereby cerhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or IJNo 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: 1 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 3op'� (ft.) I
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW 1 within 30 days of well completion per the following:
yy,,' 24a. For All Wells: Original form td Division of Water Resources (DWR),
10.Static water level below top of casing: I (ft) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If water level is above casing,use"+"
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11.BorehoIe 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 Wells:Copy to the
(ie.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
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13b.Disinfection type: granulated chlorine Amount: �
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018