GW1--05709_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
V PO Form:`: 1
1.Well Contractor Information: VVv) , 1
Ja\j Ttd� ( �� e•14.WATERZONES;S . 1r-`..;: `+ ',`7E'1;;<. . .:,4: .. f`.;.... .. . .
Well Contract Name FROM TO DESCRIPTION
gft. ft L
NC Well Contractor CertificationNumber
a 15r0UTERtt'e1SING•til mnlitailiid;wells):ORLINER(f ii'livable);; «-. . ":.,
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft aL/ ft 6 1/8 in' sd21 pvc
Company Name .^�23 V _t f., , ...
..16ANNERCASING`.OR-.TUBING aitheriia-I 1o`d"edldo) ;,;� _.....-:.-.....
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, tate,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in. '
Water Supply Well: '17:SCREEN. _ __;�+._..: . :: :: ,:,- '._-'^:; .:r: ."
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) .�Q:•esidential Water Supply(single) ft ft in.
MIndustrial/Commercial -0)Residential Water Supply(shared) t 18i'GROUf h k;_i ;; : x .' r: ,
Irrigation FROM TO _ MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft' bentonite • poured
. E3Monitoring f'Recovery ft. ft. '
Injection Well:
Aquifer Recharge
it ft.
)Groundwater Remediation
19::SAND/GRAVEL PACK(if a"pphcable '.=ys z:'." hx`i s ,, :'
Aquifer Storage and Recovery (Salinity BairleI FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20 DRILL1NGI:OG'(attach ad'difional?'s)ieeta-iiiiiiiiiaiy) a 's >_r:.is '.i
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil,.ck type,grain size,etc.)
t i in C ft. y A ,% 4,,, Ar
- 4.Date Well(s)Completed: (/ 6 ft.
Well ID# 7c ft 3e ft [�L/V
5a.Well Location: 5.b ft ,?Vat.
ed
t /I.01 e)/ti49Care ) ft. S ft C T(
Facility/Owner Name � /� '/p Facility ID#(if applicable) ft ft V•} �'=y .1 : ,F
CR 75 �1 �1 1 �VC 1 ft ft L�p�r L..1
Physical Address,/ City,and Zip ft ft S`L q /�
I) i 'ii \ ;21-RFMARKCI.r F.. ..m. ....E f: i` .3.''k V !' �L",,3
4Y
County Parcel Identification No.(PIN) • [�'t;.��.' j""7�"A., E::r:S,
�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onelat/long is sufficient) 22.Certifrcatio :
3S Q/l c N 656 43 W q (o_23
6.Is(are)the well(s)JJx Permanent or E3Temporary Signs C ed Well Contractor Date
� 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: fI Yes or t' '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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3. 6 '(ft•) 24a. For All Wells: Submit this fortn within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: l 0 (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
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.) 1
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: airpressure_ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of •
13b.Disinfection type: granulated chlorine Amount: / I Q 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 1 Revised 2-22-2016