GW1--06518_Well Construction - GW1_20241104

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- ' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information: _ - -
.3 0 Y)n IAA ILe. ..h- 7\PJ(rk,,t(
'•19..WATER ZONES '"'{;�.' -z t�.•'--.,.
Well Contractor Name FROM TO DESCRIPTION I •
LAPS 5, 82-y6t Zy Z ff. �ytu
ft. ft
I , . . •
NC Well Contractor Certification Numb er ;:15i ODTER:CASING'(lei ii ulti=cniedk"w•ells�:ORTANER(if.ap`licable);%:: '
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Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 �� ft 61/8 SDR21 PVC -
CompanyName ;r©6' y`� -.16.1NNI:RCASING.ORTEEING eothermsdclosedloo - .
2.Well Construction Permit#: FROM TO DIAMETER THICHIVFss MATExrAL
List all applicable well construction permits(i.e.NC,County,State,Variance,etc.) ft ft in. .
3.Well Use(check well use): • ft ft in.
Water Supply Well: I171'SCREEN =`;:• •.;5 ;. :-.r' e.:;•.::a:.•;;.: '::•::cs: :'•. •:. •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural [Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) It�YKesidential Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 4:18:;GRODT.:•:E : :F :• + , _... •:.^:::; �::::';r:.
[Irrigation • ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT &AMOUNT
Non-Water Supply Well: 0 ft. 20 ft.. bentonite poured
['Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft :
❑Aquifer Recharge ❑GroundwaterRemediation . g,:SANDIGRAVEL'TACK'(ifapplicable)': `•• ` '+^•7•,, -r,4;;:,:.f
"'Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft
['Experimental Technology ['Subsidence Control ft. ft.
N ❑Geothermal(Closed Loop) ['Tracer _ZO::DRILLINGLOe-(alga idaftionalah'eetaif iecessary)•=1;ii;:` -'Qx ;ta 't t •
❑Geothermal(Heating/Cooling Return) • ❑Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hariness,soO/rocktype grain size,eta.)
(� 0 ft. y� ft. Ped— 04-
' 4.Date Well(s)Completed: 1d`Z�.0/ Well ID# 1 ft• 3 6j;-A y 6i, , *, .
ft.5a.Well Location:
u ft j'
„ ,1�Mbd�d- ti t C ) ft. ft .a. ' .-...;`r. 4,-.L...,
Fjacility/O�w^ner Name �Qp�� Facility ID (if applicable)� ft ft N O V �� L. 2 C 4
/go' C ,/ "` 61 4,-, 5n, 5 Zur / Ai c ft ft
Physical
tA�ddiirreess,City and Zip / / / ft. ft f L ,' ; - `rf:
ReN'i L - Zc'(. 0 s-21:RF.MARRR,:--. ,..-..:'-'. - :..- --. 1; W is .,` .....,',
County Parcel IdentificationNo.(PIN) . •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
_ (if well field,one lat/long is sufficient) 22.Certification: • '
35, 0z5:30 N `0, 6o1971 j6--ZT--2--r
6.Is(are)the well(s): dPermanent or ❑Temporary
S. fuse of e ' eWe Contractor Date •
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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 I1No 1Sd 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 nadir#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'inRemarks Box).You may also attach additional pages if necessary.
drilled:124.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 Zia (ft.)
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:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: N (ft•) Information Processing Unit,1617 MSC,;Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699r1636
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
13a.Yield(gpm) 11 Method of test
air pressure Permit Program,1611 MSC,Raleigh,NCI 1 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