GW1--01557_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ✓
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4 W Il.€ontractor Information:
D- A . . FROM TO DESCRIPTION
Well C[on� Name Q� Q)
l QJ f�_ O10 ft. if jiZE,�l�l�h •
ft. ft. �
NC Well Contractor Certification Number • a' -i K• ---"' v°=-I - .
r�So�,.,O,U¢�R:,�ASA�iGf(fyrmulti;cseea„,well's)�O12�Z71V•F,R,(i11zp'''�licitilg)"�"s�e'`�•'� �;a:
Morgan Well,&Pump, INC .FROM T DIAMETER ' THICHIVESS MATERIAL
• 1 ft- ft 61/8 m• sdr21 pvc
Company Name- zj ' {iaffiXGOIU1LtiKGRWthepma"I?coeed oo'g)." - °. "3
2.Well Construction Permit#: e 145E1) 1 FROM. TO DIAMETER THICIQHESS MATERIAL •
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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: FROM TO DIAMETER• Y SLOT S'1LN,� •THICKNESS MATERIAL
t Agricultural 13Municipal/Public it. ,ft. • in.
•Geothermal(Heating/Cooling Supply) eBResidential Water Supply(single) ft ft - in. -
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tilndustrial/Commercial DResidential Water Supply(shared) wort-aw -
i'Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • o ft. 20 ft bentanite poured
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*Monitoring EiRecovery ft ft.
Injection Well: it. ft.
XI Aquifer Recharge - 0GroundwaterRemediation xr r�
uwatioro v o texcir ippt cable)t ,. wwEr- ,
,1I i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
.1 Aquifer Test niStormwater Drainage ft ft. .. .
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U Experimental Technology. ®I Subsidence Control . ft ft.
*Geothermal(Closed Loop) ' ©ITracer 4011DItTti7>31i 1-0 at#"icha`ii'dr'tia irelli•'. ecesea y). ' • -
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.) -,
1 I Othera Geothermal(Heating/Cooling Return) (explain under#21 Remarks) it. k.t) ft reit et1
4.Date Well(s)Completed: I f '( t Well ID# it ft .ilar
...-'1,1'.�l�.t L�f. v L.L'
5a.Well Location: 4 -5 ft. 35 ft br i *, 1/ ck- MAR 0 8 2024
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Krtc-k
;;VNA6:-,S • • .... 5
Facility/OvmerName 1 L Facility]D#(ifapplic isle) ft. ft. �0 fittt�f + e'1?'::"�° ur
to 00 (y��� L�AC ft ft.
ft. ft
Ph ccalAddresss,'Ciity,y,andZip ��)1 7.1.11�O v I t"RFllf`A`721'FC Y a " ' ' �` `�K r A.
County Parcel ldenfifica on No.(PIN) • •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laTt/long is sufficient) �/' 22.C cation:
3
,,..7„......_..) I 30 a\l,
6.Is(are)the well(s) Permanent or ®ITemporary Signs o= rtified Well Contractor Da
XI
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 11.3No with 15A NCAC 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 wider#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 1 •
9.Total well depth below land surface:545 (ft-) 24a_For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijerent(example-3@200'and 2@100) construction to the following: 1
10.Static water level below top of casing: "iJ (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 Ito sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction-method: rotary 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 Centel-,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 g- -Method of test:
nit 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: .' (5,-.. 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 1 Revised 2-22-2016