GW1--04024_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ' i
<r0 .1 Tad d, 3) '41:UWATExVONiS.i:u a . :r,-.i ka ; x=:: ;:.-'MM. :Isira c3
Well Contractor ame FROM TO DESCRIPTION •
R ft
NC Well Contractor Certification Number ?15 oiF1ER'OASINO(foimuliikcaged weB.Li 0111 NERjtf ap lieatile) 'AMorgan Weil & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
1 ft. D I ft. 61/8 . iii• SDR21 PVC
Company Name •P Y ` 'A V,�� _� ,,1 :'•IDiLVERCASIIVGOR-CUBING'(geoftieimaCeloee'R`-1 a 's.`: ,.
2.Well Construction Permit#: 1`•l V 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. in.
• ft, • ft. in.
3.Well Use(check well use):,
Water Supply Well: FROM
....t; . . -- -1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ❑Municipal/Public ft ft, in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft . in. "
❑lndustrial/Commercial ❑Residential Water Supply(shared) :ff8i'GROUTazix=^l { "'i;v n'_'_` .r..
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft• bentonite poured
[Monitoring ❑Recovery ft ft. -
•
Injection Well: •
. ft ft.
['Aquifer Recharge ❑Groundwater Remediation
4.19 SAND/GRAVXLVA K(fiapphcatile)' ;.'.% _ •...;..::'.
['Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. . ft.
❑Experimental Technology 0 Subsidence Control ft. ft
❑Geothermal(Closed Loop) OTracer 20 FDRMIZINGTOG ddifionarAiiiti if necaasry). . .�„, f>u;
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: J^ vM ID
� ^ Well # go ft ( ) ft 'S'Q n6\1. 28(,1-,-., ,
5a.Well Location: .) .ft., t fticy 4/INt - 1 C+C7 W . i , G, A o 7G ft ` &imovii .
Facility/Owner Name Facility ID#(if applicable) • ft' ft.
Physical Address,City,and Zip ft' ft.V.,ri� -`� ` ",21?RFICTARKR - - - :. a ti.L A':$ 4`;. 1
County Parcel Identification No.(PIN) law Alra.64'1 i)'^"-'al*.-:w''.j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWI:,3Cv
(if well field,one Lt/long is sufficient) 22.Certification: '
3s ,s9 /// N ?h0Cra33 W • / -fi`-L7't/
6.Is(are)the well(s): n1Permanent or ❑Temporary Signa of Certified ell ontractor Date
By signing this form,'hereby certify,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and plain the nature of the of this record has been provided to the well owner. '
repair under#11 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (Z.50 (ft)
For multiple wells list all depths if different(example-3Q200'and 2(a)100) Submit this GW-1 within 30 days of well completion per the following:
'casing: ` • 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of
✓-� (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" •
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter 6 (in,)
Prograrn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rota•Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
2
13a.Yield(gpm) J Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
granulated'chlorine v'
13b.Disinfection type: • Amount: 1 •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018