GW1--05756_Well Construction - GW1_20230905

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.We Contractor Information:
•
• 4, I
;i1,4 WATERZONES',r WRx t _: ':.{-I:.r. .
Well C tra tor Name FROM TO DESCRIPTION
n'� ft ft C
' 4 L�. A ft ft
NC Well Contractor Certification Number -
'15iO.IITER',Ge+iSING.(foi mul[i casetLR ell`s);OR7�VER(iL'a"p'lic`a"b7e)xi;�V„=?>;1:4I;
Morgan,Well&Pump, INC FROM T DIAMETER ! THICKNESS MATERIAL
1 ft. ft. 61/8 m' sdr21 pvc
Company Name, .._.._,:�,_
p�\ /1� �r 161 NEBSC• OR:T'IIBING(o't5e`rma1'dose'd]oop)_�_.. . .
2.Well Construction Permit#:UA\f'� ii.r l�jj ,:o 3 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:
;.17CiSCREEN<.'• 7 s.3. >r1-.:'�?-4 i 1'=:i .:
• FROM TO DIAMETER •SLOT SIZE THICKNESS • MATERIAL
*Agricultural jMunicipal/Public ft ft.' in. .
•Geothermal(Heating/Cooling Supply) "'iResidential Water Supply(single) ft. ft in.
It Industrial/Commercial %iResidential Water Supply(shared) - . •
• =:15::GROUTi'�::ri i:`.. ';' .-tf�.1- ;a
i Irrigation FROM TO MATERIAL! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
NI Monitoring DRecovery ft ft
Injection Well:
' ft. ft
_Aquifer Recharge Groundwater Remediation
`19a.SAND/GR'A�!II;;PACK if,app'liceble�'c.. ' ''w r'ti,::= `s:.`.F' a'..:?
�'.Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD`
Aquifer Test D Stormwater Drainage ft ft
U Experimental Technology 0Subsidence Control ft ft
•Geothermal(Closed Loop) Tracer ZU=DItI1 II!1G-LO;G'(attach='e'dditional"ilii ts':if ne'ce`s'sary)s .'_=r .-' :V_-_;2s i''?'::+
7. Geothermal(Heating/Cooling Return) rI Other(explain under#21 Remarks) oM TO DESCRIPTION color,hardness,soiUrock type grain size,etc.)
�f��� ft #is ft 'b/ Vs1,�A
4.Date Well(s)Completed: I f#� � Well 1D# \O ft T
`lftiQ `t„ cak . • t
.Well Location: x Se) ft. ft t�`v.t � �,, ,I
ft. ft I✓ �.t
Facility/Owner Name Facility 1D#(if applicable) ft ft. ' l r`•t.'-'14 i"a
L4rl L)1 ?Ivroer-&
ft ft i s i t ik ig f y
t . .4 �
ysical Address,City,and Zip NC
rC�8.1 1h1 ft ft. S E P J 5 :2023
US Jv O��'G ti21::RRMARRs - .':.;s. .a`•'.,'.
County Parcel Identification No.(PIN) inforcr,atta.n Pro i 1.:tl3i
DYv4y:Oto •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • / ,
(if well field,one 1� ng is sufficient) ] 22.C• :• cation: •
- s,. 4.
e Sign!• if .ed Well"CCoontractor D te
6.Is(are)the wells)f Permanent or DiT mporary
By s a ing ih'rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II Yes or ifiNo with 1SA NCAC 02C.0100 or 1SA 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:t 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: ) (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.) 1
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(gpm) Method of test: !
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine 16 Or- 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