GW1--06366_Well Construction - GW1_20230927

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WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: 1 ,
,1.Well Contractor Information: i
i
i14`WAryatzo ES„. ?}xis >;.i.>',;`s.A—. . .a _. . ." ,. ..•
• FROM TO DESCRIPTION I
Well C tra for Name ft ft
427.--A. . .. ft. ft. I 1
NC Well Contractor Certification Number ,15'OUTERCASING;(fomm�lti:ca'sedlvells)Alt'7�2PIER`(tfap`licab'le)°:;i.2 Z:' r is
Morgan Well &Pump, INC FROM I{-TO DIAMETER 1 THICKNESS MATERIAL '
1 ft �/,�15 ft. 6 1/8 m• sdr21 pvc
Company Name• (J[ .._.. ..., :,•.
P y 16 IlVNER;CASING.OR'TIIBING(geotliermalelosedloop) . a, ;_r= ''• tw.
2.Well Construction Permit#: `' 054-.40. -s--1 l vk la- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits( UIC,County,State,Variance,etc.) ft. ft. in.
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3.Well Use(check well use): ft ft. in.
Water Supply Well: y17:`SCREEN ti.. .<` ..'; i:. • .
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural DIMunicipal/Public ft ft. in. .
•Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft in. '
iIndustrial/Commercial Residential Water Supply(shared) ,.,.�. •--
!i Irrigation FROM TO MATERIAL'-,. •�EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
**Monitoring )Recovery ft. ft.
Injection Well: ft ft
E3 Aquifer Recharge in Groundwater Remediation _;-.,,.,,,.z..
•r',''19:SANDIGRAVEL.PACK(if:3pplicable)'cS 2 :t.':,F-^;`:„ ,'"i':
ElIAquifer Storage and Recovery EDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft ft.
Li Experimental Technology ElISubsidence Control ft. ft.
Geothermal(Closed Loop) In TracerLj >.20fliRl) NGLOG(aitac ad'ditiouaIshee`tilt' eceessaryja'.:-:"'-:"" "-"'" _
Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
/` ft ,� ft. �+� ���
4.Date Well(s) �'1 �S Completed it I Well LD# t5 ft fit+ ft ly.'AAA—
5a.Well Location: VS ft SC ft WYt f J
' ,•e-voir 1ms' 50 ft .S ft. ii_ esf)wttr
Facility/Owner Name Facility ID#(if applicable) ft ft.
ft ft M.:.F f +r, -°: r,...
Physical Address,City,and Zip �•y�.•��6 `q ft ft �"`�^ h-'.r �f --
l ' V • • S '21�RF.NiARKR s'i-t_-.a_....... .., ,',',',{': i,.. .'..(t;..r.'= ?_t d:";=i:=
County . Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L; J.• .-,7 r
(if well field,one 1at/long is sufficient) 22.C- ., cation:
35 .Seib N 14.S1. .cajZ`7 WggsofraL . -
6.Is(are)the well(s)�IPermanent or Temporary Si
gnagf ed Well Contractor Dat
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By sung th• "•res,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 11No with 15ANCAC 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 ofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells laving 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 QC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O J (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:.. IS (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 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:
(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,l Raleigh,NC 27699-1636
air pressure24c.For Water Supply&Injection`Wells: In addition to sending Yield(gpm) �O Method of test: the form to
the address(es) above, also submit one copy of this form within 30 days of,
granulated chlorine completion of well construction to the countyhealth department of the coon
13b.Disinfection type: Amount: `L PP ty
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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