GW1--01571_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
l W 11f,ontr actor Informatit.
on:
�I/1 . ..
.gaits ATER)7A'.'$: 2 fraa'.x''.v�d'y".'.S:z�`:z ir"',t�->,�% :„„.lf e. sc"o�.l•?•'2 . x.'�a.-�o.'h
Well Cont� ,^�^^��Name/�, ` f FROM TO DESCRIPTION
•
3'L t45 it 'b ft. I .
ft. ft • i
NC Well Contractor Certification Number o- ^- �"�
s,I5'•O.tftR;OASINiak ormulti cssi*v ell's)1OKMER;(if�ip i<cab'larrA 'z��e
Morgan WeII.&Pump, INC FROM TO • DIAMETER THICKNESS MATERIAL
1 ft `k6 ft 61/8 mn' sdr21 pvc
' Company Name. r ti a�- u 3
...���///��� :16!�TNILVEIt:QASIPIGOR3PUBIl!>`Gr�therm'a"l c5oeed?loo� a�.
2.Well Construction Permit#: 4 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI,C nty,State,Variance,etc.) 'ft. ft. . in. .
3:Well Use(check well use): /�j fft.. ft. in.
�3�y .
1P1�/+iSI E1N ..�G4i i% Y':SwF.1t1itt isrc TriMa--•r?Niul
Water Supply Well: FROM TO • • DIAMETER SLOT SIZE .THICKNESS MATERIAL
[J Agricultural • 0Municipal/Public ft. •ft. in. •
0Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) {t. ft. in. -
DIndustriai/Commercial . LResidential Water Supply(shared) e•F-G -D ,n r�g „±s „.•. ,,#„ �'-�
riIlrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • o ft 20 ft bentonite poured
IIMonitoring . DRecovery it ft.
Injection Well: •
{t ft
Aquifer Recharge . - lJ Groundwater Remediation �r u: .� _.
I4 SriRr L-IM M(iGapplicnlil'egT-Mt,:.3rOMZ`:•-:. .as is �r'``'s
EllAquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft. ..
Experimental Technology.. fl Subsidence Control . ft ft.
(Geothermal(Closed Loop) (Tracer 2o'tipIiTl U"Ik�T .,l✓"O;Matft ch adaill'ir trnecesiatl7 a`ram
FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) lJ Other(explain under#21 Remarks) {t. ft yry,C e���
4.Date Well(s)Completed: l k5•\' Well ID# • 15 ft 46 ft.la1 .A irk r :- - �'�:c"^ : A �-
4� ft u� it ��� --'L' ._ i .X I.-
5a. /elllLocation: - wit
Nbe.` 1 • - 15 ft too ft. Aci MAR 0 8 2024
Facility/Owner Name Facility ID#(if applicable) t}i� ft. 3(5 ft. �`I'�� . ry��
Wa, ft. ft. V gWi`�iG ii c+...,n. •..... •eos: (iFi
\(2S\S..bo6VTA fL 21o1 aW�� .x;
Physical Adddrressss,,City,and Zip i h f w ft. ft
-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) Q5L2. - 22.C cation: r 77Va i316 1 N <Qe l w . .! Da(11„e�b �((
L 1 . L
6.Is(are)the well(s) Xi permanent or ©1Temporary • Sigma o reflect Well Contractor
By ing form,I hereby certr;/y that the well(s)was'(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or XBNo 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 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: 3(05 (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:
-3
10.Static water level below top of casing: a�V (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 Om) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rota" 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 Centi r,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: 15 n . completion of well construction to the county health department of the county
where constructed. II
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016