GW1--05752_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
,,1.Well Contractor Information:
140;V TERZONES''='.," .: iti t: fi I.:"AW_1l.i.k n"r. .. ..•.
FROM TO DESCRIPTION!
Well C tra tor Name
it ft
e3(42z . ft ft 1 1
NC Well Contractor Certifi cation Number 1LS Qi3TER.Ge1SIPIG`(fo"'r miilfi caserlwells)OR�L`INER(ifs}i'licible)==.; ;f-F.`rzi Fr
Morgan Well &Pump, INC FROM T DIAMETER! I THICKNESS MATERIAL
1 ft. ft. 61/8 lm' sd21 pvc
Company Name , i �g _"16?.1NNERG GQR"LuSING.Veitheiiiiircltided iibli ;= .:ii. t .,
2.Well Construction Permit#: •eAV- 1` I/ --t(j. FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft 'in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 175'.SCREEN 'c ..__"_ s':. "s vY' :
�, , FROM TO "~`�o-DL1METERa~SLOT SIZE . THICKNESS MATERIAL
• 'Agricultural 1�Municipal/Public ft it. in.
Geothermal(Heating/Cooling Supply) iResidential Water Supply(single) ft ft in.
!Indushia1/Commercial . DResidential Water Supply(shared) 4:18i�GROIIT t` .;'.i.„..-.%:�:`-:;a;>7:':'"".'.z •: i'. .
hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft ft
Injection Well:
•
ft. ft.
Aquifer Recharge [I�J Groundwater Remediation
19:'Se1NDIGRAVEL PACK(if ajiphcable) :;' u_r, =1 *' 2±;a
Aquifer Storage and Recovery �Sidinjty Barrier FROM TO MATERIAL'.
TEMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology I Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer i1,20 ilaraD IOIOG(atiich erTditionalsli tsflifE awry);; ?r:;:ei ; ,f,e
FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.) •
!!Geothermal(Heating/Cooling Return) riIOther(explain under#21 Remarks) ft �S.� ft r y� l
,l r� 1i
4.Date Well(s)Completed: 14 it � Well ID# it ire. ft �y tit
5a.Well Lo on: �, ft 1`:_: Frsrr V SNI-1 t` .� ft
Facility/Owner Npme, Facility ID#(if applicable) it ft i r''
j'4tb /43- (?'At �n. thi , ��k) ft ft ' \c 1„,IL:i I/ 6.f
P sical Address,City,and Zip ft. ft (�t;.C n
I tit gy,DgARK.S, '4�::—- :::77. A's'.�-�. >:_�-} '7g,:.'c.,_i J.2.3f'%a;1-
County . Parcel Identification No.(PIN) . 1nfnr%r'4ta'1 r"tI.^.. , ,..,;j-4 L`t
cii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • D�a�J��
(if well field.one
_llaatt//l�ong is suff cient) ( ��y 22.C cation:3 .. �+LT N lxJL ./ 7 �F' t is [93
6.Is(are)the well(s)+Permanent or 0Temporary
Signa..i ;'f . •ied Well Contractor
By s_ ing th. '.rm,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 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:1 fy SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form 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: 35 (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 ;
(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
air pressure 24c.For Water Supply&Injection Wells: In'addition to sendingthe form to
13a.Yield(gpmk: Method of test:
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'granulated chlorine Amount: �(��rr22��f 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 I Revised 2-22-2016