GW1--04841_Well Construction - GW1_20230728

• . YYJl,L11. LU1N b IItULJ-101N RECORD(GW-1) ForInteralUseOnly:. - •
1.W ontractor ation: •' •'
,." • y
'14:,WATER ZONES - ... .. •.-_. , . :
•Well Con tor
LLl �e - • ' FROM TO DESCRIPTION ,
�,f r ft ft.
e t ft f.
NC Well Contractor Certification Number '15:0 U'JeR_G2ASING,('for multi=diced` )yells O_R ,1/T (Tap'livable' ::',::::'
Morgan Well & Pump, Inc. - FROM TO' DIAMETER • THICIfi TESS p MATERIAL
+1 ft. 4 ft 6 1181 'in' sdt21 pvc•
Company Name
2.Well Construction Permit# v� 16:II R C' G OR:.1:W37I5G:(Teotlieimal..absed--loop)?,;:.;-'••_' •'•'••;I': ,
-r/ W f°• � FROM TO DTA M'aTER. THICENESS M'A.TRRTAL.
List all applicable well construction permits i.e.!UI'C,County,State,Variance,etc.)• ft. ft. . ID. •
3.Well Use(check well use): ft ft: in
•
Water Supple Well: . . 17--SCREEN'.:-. :.. . -••=•`_• _ •:•:. ::� , : 'S.:;•::t,.:_ ,,-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Aglicultural DMunicipal/Public • ft ft in.
i Geothermal(Heating/Cooling Supply) 4PResidential Water Supply(single) ft • - ft in. -
I rndustrial/Commercial • OResidential Water Supply(shared) ::18:GROUT::• :; _: r'`= :: - -1:`,:,
jIuigation . . FROM TO MATERIAL EMPLACEMENT METHOD'&AMODNT
Non-Water Supply Well: a ft 20 ft bentonite• poured
' 31Monitoring DRecovery ft. ft. .
Injection.Well: -
�-{ ft ft
_I Aquifer Recharge !-'f Groundwater Remediation •
:.7.9:SAND/GRAVEL'PACK(if applicable)•-:.::.:-'Z,: '':.•' -'' `•':2••.:':''%.
Aquifer Storage and Recovery DSalinity Bather FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test • JStormwater Drainage ft. ft. '
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) oTracer . , .20.DRht IlGZOG•(aitacliidditional/6ietsifaeces'sa.rpj;-t :`.i _ .
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) -PROM TO DESCRIPTION(cater,hardness,soil/rack type,grain sae,etc)
/ a o .ft. 5 ft, r{d dim ••
4.Date Well(s)Completed:(p 1 3®1�3 Well ID# C' • ft 15 ft. tewh a`rt.
52 Well Location: l5 ft ft Dr 3448 raft •
.. ft ) ft. �VV� (LFacility/� ner JY\&ff
Facility DD#(if applicable) _J ft. ft g
14 5 to \� INA IL tic, l ft. ft. " . �� V i
/1PhysicalAddress,City,and Zip ft ft Aft n,n
1� � :21:'RFMeRuc : -... .- . .. -. :. , =_.,J •.U.-L:a:.=:.
County Parcel Identification No.(PIN) In r.a:,tfr�,.�'
D1,1/Q13Qla 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one latflong is sutncient) 241,.ration'
2=27, • .. •
35 N d. -1rj W
. -.
6.Is(are)the wells) Permanent or 0Temporary Signa,e I :.ed Well Contractor •Date
3614K-
B fmsi s is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 'Yes or •No with'1SANA•C 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a •
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: AO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells li l all depths 1f-diferent(example-3(200'and 2@ 100) construction to the following:
10.Static water level below top of casing: (3(5 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
~11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: O t J
construction to the following:
(Le.auger,rotary,cable,direct push,etc.) - • •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gem) Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
Ithe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type� 1r`N�j Amount: completion of well construction to the county health department of the county
where construbted-
Fern GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised2-222016