GW1--00837_Well Construction - GW1_20240205

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• WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
4 W 11 Contractor Information:
AA f4ATER.70PNF S-r�_`S3 L� ?: 3 � x`1� r� roolmti`� 0
FROM TO DESCRIPTION
Well Con.3 Ink'� ]Name A
(aC ft (C ft 3 I •
i
v�� • J �I - .
ft. ft
NC Well Contractor Certification Number 2 OUii°t HyarSR CY(formvl)iF aseane i"`e71a}OR IER;(iftzp licab�leMa • -
Morgan Wefl.&Pump, INC .FROM TO DIAMETER I THICKNESS MATERIAL
• 1 ft ft 61/8 I mi sd21 pvo •
.�. �.b. �.• .t-
Company Name (� C!-It%340.0$X rQI . _I areffierma'It_c"1, Idler.) _ ` .
2.Well Construction Permit#: —kt FROM. TO DIAMETER ' TRCFQESs MATERIAL..
List all applicable well construction permits(i.e. County,State,Variance,etc) 'ft ft in.
3:Well Use(check well use): ft ft in.
iTZ$ a gym" —t �ca_ur .r" rya ._as xr A
Water Supply Well: FROM TO • • DIAMETER 'SLOT SIZE •THICKNESS MATERIAL
Agricultural jMunicipal/Public ft. .ft. • in.
Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) g, ft in. .
Industrial/Commercial DResidential Water Supply(shared) S -io. r gwir_ 1s
Irrigation FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite , poured
•
Monitoring Recovery - ft ft
Injection Well: ft ft. •
Aquifer Recharge . J0GroundwaterRemediation r - s w� v x J
so-o�( L'y$rigri(rfzPP c$liTejle�r.it'.: axe -e: `^a .
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test al Stormwater Drainage ft ft. .. .
Experimental Technology. ®ISubsidence Control . ft. ft.
Geothermal(Closed Loop) 10Tracer 0.FpTGJ.xQ:(U ati%chlad'drtiou r]eetr:. eceslist3il'
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.) ,
Geothermal(Heating/Coolin11g Return)
I nj Othdr(explain under#21 Remarks) O ft �S ft redC1\
4.Date Well(s)Completed: l In 1 Well DM `�j ft C45 ft N f-n e y 'C �.k
5a.Well Location: 444 elS ft FlO ft. by&oh 1 ifiG ,
l(7.1I►/oWd � SL� L it. ft. 'Ulf Cytkitt CL[ c: l �sC :i�'
Facility/OwnerNa�re FacilityID#(if applicable) !� r ••""LI
ft. • ft. F• EE;
V 5 20
• 34Sa t'a-6tcc k tail \plota k.eck Mc.a-'io5� 24
P}lysicalAddress,City,and Zip ft. ft i do ul -.jj l
�, .( ;;
County Parcel Iden6ficationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.C cation: •
3S.TOCI.5 N (ZU.5(01:a—.. W .,.J '
I' lLa-5 ( d-4.
6.Is(are)the well(s) X Permanent or Temporary Sigoa o reified Well Contractor Da
By ' ing form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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: .300 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100) construction to the following i
10.Static water level below top of casing: 3S (ft.) Division of Water Resources,Information Processing Unit, .
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 • (.11•) 24b.For Injection Wells: In addition td 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 •
13a.Yield(gpm) 3 .Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one(copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: • l?0� completion of well construction to the cl unty health department of the county
where constructed.
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016
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