GW1--06354_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1
1.We Contractor Information: 4M1 s ' - I l
UCfCl. 6 I
"14.RPATERZQIVES '.�. » '!=• .p:.I'" .
L FROM TO DESCRIPTION I
Well C tra for Name it ft
342Z ft ft
NC Well Contractor Certification Number .05 t)L7TER;CASIIkG(f'oyJ4ulhrrased_i`"e11s)=OItL VF3;(>tsp-lieab7e)z 5?=+ `5' •'1
Morgan Well&Pump, INC FROM ;g O n T 1 I THICKNESS MA
TERIAL
it 4 ft 61/8 il•I sdr21 pvc
Company Name , ^ =16; V IERCAS'IL�IG:OR0yU13ING`r eothe maLblose uop'):: N;%:�._;>f}f.x '::1
FROM TO DIAMETER r : THICKNESS MATERIAL
2.Well Construction Permit#: J{\
List all applicable well construction permits(i. VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): . ft ft •
t17:SOREEN4 `.'iti_ :V11.:.:i r; -•r. ,.:= .r°.<a f.• . %:
Water Supply Well: FROM' TO DIAMETER SLOT SIZE THIC"ICNESSMATERIAL
•Agricultural ).Municipal/Public ft. ft in.
X Geothermal(Heating/Cooling Supply) ©II Residential Water Supply(single) it ft in. '
Residential Water Supply(shared) .1.0 GRC)UTI,r .i'.,, ..,.-:,.<-.�,-'-::r s,-=;:: _•• .
j�i Industrial/Commercial PP Y 7: ;'�,:R;.,?• : . .. .,-.w_......_,. -.. :-:
1 Irrigation. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft Y0 ft bentonite poured
•IMonitoring ®IJ Recovery ft. ft.
Injection Well: ft. ft.
(Aquifer Recharge D Groundwater Remediation a"i9:SAkW/GR'A EIAPAt (iCapp1ieablert ' . - . '
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft ft.
U Experimental Technology i�1 Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer xQ.9? 'INGIO;G,(attic eaditional'slieift.i�'necessiii0:...u, �Kla'a ;=!EkI
FROM TO DESCRIPTION(color,hardness,sviltrock type,grain size,etc.)
LI Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ft ft. �'y,� �`
4.Date Well(s)Completed'3t 1P-7S Well ID# `b it
X7 ft Aiy L
5a.Well Location: ft 3b ft k7osa.,•'ric,��`-
•
36 ft. rim) ft aY I yl
FacilitytrIft
ID#(if applicable) ft. ft U .
Facility/Owner Name `w` r, it PP )) yam'^ q
-tc F AV.A,\, ., v�.� J CtAx ra 1ann ft ft i'I"' i4" �0 ���! �1_ ,
ft ft I Y ~
- /PPhy//siicaal�l Address,yy City,and Zip "`JJJ f t^ . ^
\ 06adViai S z21 RFM41110 .,.. .. .-.. .-'.7i'. 't?:-.Nfii:: i-2;F gift`=t: �:,,_.,...
I County . Parcel Identification No.(PIN) s-, r,,t,-,.-1�•++.-.4:.N.1,.j t Err.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I C "^t�' `c`4
(if well field,one lat/long is sufficient) 22.C • cation:
3S.3533 N `go• (off 5 w � - 'i_l_5_11.).1
•
6.Is(are)the well(s)80Permanent or Ei Temporary
Sign f .,g;:. •
ed Well Contractor Dat
By s mg th, 'nn,I hereby certify' that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or +No with 15ANCAC 02C.0100 or ISA 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: OC (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example- 200'and 2@100' construction to the following: I
10.Static water level below 5 top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing;use"+" 1617 Mail Service Cent'r,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (m•) 24b.For Infection 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: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CentI r,Raleigh,NC 27699-1636
13a.Yield(gpm) `, Method of test: air pressure 24c.For Water Supply&Infection Wells:
lls: In addition to sending the form to
the address(es) above, also submit onej copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 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