GW1--05779_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information: I .
i I
`14 WATER'ZONE5a;i• iaa r..:=:c r.R ;?t. F.-. 1.'51X41-i;;t=xs�'%-!..: ....
Well C tra tor Name •
FROM TO DESCRIPTION! v.
3�4 - it 15 ft. i' ft }
NC Well Contractor Certification Number :'15i;QUTER CASING'(f Erniiit easedwells)OK`LINER:(it'sp"licab`le)i=ff€=:u:g'
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ':ak ft 61/8 !n'. sdr21 pvc
Company Name• �. -. .
11 -..<t.G011;TUBING(geotfier�malcioeed' dopy) .1
2.Well Construction Permit#�' - n" p� FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permis(i.e.UI , ounty,State,Variance,etc) ft ft. in.
•
3.Well Use(check well use): ft ft in. .
Water Supply Well: .1i1SCREEft"a'4if.ii4.V.-. i3_:,' ' sr%':r_•,- ,,c- r;:S'A%; r t= V :'
FROM TO -DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural DMunicipal/Public ft. ft. in.
U Geothermal(Heating/Cooling Supply) I Residential Water Supply(single) p, ft in. •
*Industrial/Commercial . DResidential Water Supply(shared)
a$:;GROUTiS' -.1;js't.t;.L•.+. t§li k:.: .
4;ll Irrigation FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . o ft -20 ft bentonite . poured
%'Monitoring DRecovery ft. ft.
Injection Well:
ft ft. '
_Aquifer Recharge' Liii Groundwater Remediation -
t1'19::SAND/GRAVEL•PAC&'(if apiiltcable) ,-,, if-I' := iZi ' s. 3'Oi"r.�...,;::t.:�=" are..
. Aquifer Storage and Recovery EllSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStomiwater Drainage ft ft ,
L Experimental Technology DII Subsidence Control ft. ft.
Geothermal(Closed Loop) ]Tracer 1 20 1SOMLINGTO:G(attacl aiiditio'naksheets'ifnecestarY)5i
I-_�Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To yDEESCRH DESCRIPTION color,hardness,soillrock type,grain size,eta)
( PIZ)
u It. C) ft !eridl4.Date Well(s)Completed`��{ Well ID# [ ft ft S =15 ft. /o ft
Sa�.1Well Location: •
/ G 1J �j�Qt s, �(, �<,Q
`I tl l\``CAV' ' � \\ , -L 45 ft.ft � $ft V -� �`-' ,.w.
Facility/Owner Name F ility ID#(if applicable) C�,e�i Vf 1—1 '
q(--.)---aldt 5--hoot Y �-4 ©� it ft. S E P J 5 2023
P�sical Address,City,and Zip ft It - ,,- -:4 .
CI ( '3,`21�REIVIARTfS::> " -=" =N `-?,:,i;: :'F. -x''`. ,:, 1,raSa.i.>::n.,.i.
County . Parcel Identification No.(PIN) DIQQ/ OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) W22.C • cation:N r9/016
..."'
6.Is(are)the well(s)>�IPermanent or DITemporary Signa f .ed Well Contractor ate
By s ing ihrm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes 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]mown 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: 69eS (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 00'and 2(41100') 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 caring,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:
(Le.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 sending Yield(gpm) C) Method of test: the form to
the address(es) above, also submit one{copy of this form within 30 days of
13b.Disinfection type: granulated chlorine _ Amount: ' completion of well construction to the coriinty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016