GW1--04866_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
0 AN,ame 1+-d -1- :tea rwAi7 itzoi s,' =v. ; ;:
FROM TO DESCRIPTION
Well Contractor
�5� ft. ft
it ft
NC Well Contractor Certification Number g 13;OI1:libg Cr1SING.(tor multi cos`edty"Tel s)OR L'INER(l ap`hcablej;2M E
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft 1,2.91
ft 6 1/8 in* sdr21 pvc
Company Name 16::INNER`CASINGOR LUBING'(geotieermaldoeed'1od 2.- ri °"
2.Well Construction Permit#: oS tlip-�I.�3`• !7 as FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIGCCC",County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
L17 S.CREENY
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural J Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) I Residential Water Supply(single) ft ft. in.
DIndustrial/Commercial Residential Water Supply(shared) g1$4-.G ROUTu% - -=-., __
r'4Irrigation .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ' ft 20 ft bentonite poured
Monitoring r3Recovery ft ft.
Injection Well:
ft. ft
{._`Aquifer Recharge �J Groundwater Remediation
L 19`Se1ND/GRAVES P CBS(if`appheLble):":w t_ a_z
L'Aquifer Storage and Recovery ) Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_I Aquifer Test DiStormwater Drainage ft ft.
1 Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) llTracer f z0 1)RIL>ING 'O.G(atfach;add7honalslieets3fpeceasary)l e. > .„-'
Geothermal(Heating/Cooling Retum) IOther(explain under#21 Remarks) FROM .TO DESCRIPTIO (color,hardness,soil/rock type,grain size,etc.)l
•
/�7 �7 •
ft. r.]� ft. VO,Aii)
CI l 14.Date Well(s)Completed: -` -L Well TD# C/OftJJQ 5ft. !!!! /l% Fi
5a.Well Location: 5. ft /. ft 'Q� v" ` zx
/V;/lu A/Y1'.G� 115 ft. j5ft 1 INC 0 i l-2
Facility/Owner Name /� P /,Facciliity ID#(if(i applicable) ft. ft r t_r1 c,• .a..
7 /-� pro �T /•vl/ 1 f . ft ft - ,,,,y : .p
Physical Address,City,and Zip ft. ft JUL 2 8 202
SREM RIBS':_,._„-, ti _` :. _: ; ..
.Ltdc -1 ? 5,21 Intor;r aa ,,,T� .. x
County Parcel Identification No.(PIN) VJw=iC.Ra
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
35 5/ Ill •N a-9/61/6 W -di" , ? 17-Z3
6.Is(are)the well(s) Permanent or DI Temporary Signatur..f ell n or Date
II IX
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes. or XI No with 15A NCAC 02C.0100 or 15A 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:' . SUBMTTTALINSTRUCTIONS
9.Total well depth below land surface: 456 (ft..) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Iist all depths if different(example-3@.200'and 2@100) construction to the following:
10.Static water level below top of casing: 9 (ft-) Division of Water Resources,Information Processing Unit,
If water 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
rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) " Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
O S bZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type granulated chlorine Amount: 6 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016