GW1--06516_Well Construction - GW1_20241104

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: - •_
3o\r‘in '.,u Y-e.
6-7 V\JaAtr
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Well Con tractorrName� FROM TO DESCRIPTION I
�V`1A I' ft ,6Q' ft. 2.. ftt1I
ft / ft !'
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NC Well Contractor Certification Number ;:15:•OUTER:CASING(foi•multi-caiedxi"velli)!OR7MER(if1—lichble);i.- :`'.-.
Morgan Well & Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL -
1 ft. S 4 ft 61/8 ' SDR21 PVC
Company Name 3}^1 o v�
".16"'��_(�' f � :IN1�IiCASING.OR TUBING(geothermsl•closed-loop):;-:•i�;�,-`:,;
2.Well Construction Permit#: l FROM TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. m-
3.•Well Use(check well use): • ft it in.
Water Supply Well i;17iSCREEN'_:.:;:•`_-r. •.-.:. -t-:. : .r`.:4;'s�-.:.•;...''.: • : :;!.:':-, •
FROM - TO DIAMETER SLOT SIZE _ TEIMIINESS MATERIAL -
• ❑Agricultural . ❑Municipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) 1t esidential Water Supply(single) ft ft in.
❑Indust:dal/Commercial ['Residential Water Supply l (shared)
:., ••:;
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ' .EMPLACEMENTMETHOD&AMotur
Non-Water Supply Well: • 0 R' 20 ft bentonite, poured
❑Monitoring DRecovery ft. ft.
Injection Well:
ft ft
DAquifer Recharge ❑Groundwater Remediation :; ;
.1.19.:SAND/GRAV.EL`TACK'('if applicable)'> : :s-, `•c ::::=._-' :: :•:a�:-.:•:-l.:
['Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
['Geothermal(Closed Loop) OTracer i.20:DRMLINGLOG(ettac'lia'dditi6n51eheetdifriece3sai-k).h::"c `a`., .-:.'c;' V •
0 Geothermal(Heating/CoolingReturn) 0 Other(explainunder#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype grain size,etc.)
6 ft 3 2- fr. PCd- 0/4-
• 4.Date Well(s)Completed: /O' l—may Well ID# 33 ft ZOO ft 6,- G t
5a.Well Location: ft. •
ft. J _
Facility 6wwuer Name Facility ID#(if applicable) ft• ft. .
0 p4-K . n1 6 i2J k'v►n API)5 Ak- ft. ft. NOV t3 ' 21124
A ft. f t
Pal Address,City,and Zip ~= '.:^'_;,,.. •'•_ V .
Ili°.�, �--,.,!.7.,,,a— r._.r
County ` y Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one tat/long is sufficient) 22.Certification: ,
3
5� 51 lvg N _go. 71351�P W la-i Saur::4 e6.Is(are)the well(s): L�Permanent or ❑Temporary '
' ed We CII ontractor Date
. By signing this form,form,Ihereby cer1ij5'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 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.
drilled: , 24.SUBMITTAL INSTRUCTIONS
2�9.Total well depth below land surface: (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if d(erent(example-3@200'and 2@100'),
f7 24a. For All Wells: Original form to I,Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft') Information Processing Unit, MSC!Raleigh,NC 27699-1617
If water level is above casing:use"+" I, ,
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: 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
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i I
granulated chlorine 1 I
13b.Disinfection type: Amount: tit
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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