GW1--06022_Well Construction - GW1_20241011

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
• 1.Well Contractor Information:
• TOCU . �:x4„WATERvZONE5:.,. -::-a:trt : i:::! .Y.`i...... .-. ... ":{;. €:t.. ,
�e on ra Name FROM TO DESCRIPTION
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4 - v).1., ft ft t v ti sl
NC Well Contractor Certification Number 15J.Ot ER;GASING•(fdr innit iibiie4 well's)•ORX AVEIt(fCap•Iicalile)::' u:%%;?: >
Morgan Well&Pump, INC • FROM O DIAMETERi , THICKNESS MATERIAL •
Company Name 0 ft ft 6115 in• sdr-21 PVC
kac`^s5� ..zad tINERiC• G;Alt:1:uBI1G,(geo,•tEeimaiclosed-loopi,::":, :.;:�';:r:i,yc..`:•"::r;::
2.Well Construction Permit#: FROM • TO DIAMETER' THICKNESS MATERIAL
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: >X74SCILEEN. •:. :.r:. ::ti F::..:,:.,,=..;'.. ;
.•::;• .:::.r. -::..,•, ^;.>.•`.,
FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural 0Municipal/Public ft it in.
X Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ft ft in. ;
X Industrial/Commercial DResidential Water Supply(shared)
:.IS GROUx ... ..
litigation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• al ft- bentonite poured
X Monitoring Recovery ft. ft.
Injection Well:
X'Aquifer Recharge ft. ft.
J Groundwater :19.SANDJGRA'VEL'PACK(if applicable) -•.:. • ,• -':' .
III Aquifer Storage and Recovery r3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test 0 Stormwater Drainage ft. ft.
X Experimental Technology )Subsidence Control ft. ft. '
X Geothermal(Closed Loop) r-t6Tracer 20:.DRILLIlV0L1:1G:'attach,••additionaI'slieetsifnecess ' •'-'i
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 4
�� Well ID# y tsd ft 5 ft. ra 6
ft b ft. r 1w yt
5a ell Location: `0 ft 5 it trotn..1-ock. S el
kkeLVAcon 5 ft Sao ft. , 3rc C.)
Facility/Ownci Name AA !! //Facility ID#(if applicable)r10� ft ft.
%0 . ,L.[.�..`\/ V` t ` e 22b ft ft ; a E;,;,..,,A,....,,k..--'t. ';:y,-'Fes;)
Physical Address,City,and Zip • 3 ft ft • n C T I 1
(131186VN ^�0c14M11`4?..W.s1 ti :Y:; ::.:'i,"1fi1 r: f E wis:,ystf: ,7�..,7_;
ounty Parcel Identification No.(PIN) - "hv
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one le/long is sufficient) 22.Cer.cation: .
.35 t �3 N7f4,a/CA W ► op
6.Is(are)the well(s)JPermanent or Temporary Signature. e led Well Contractor Date
- By sig _ is ,I hereby certifi,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or }No with 1 r A :: C.0100 or ISA 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 o 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:' b . SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 15 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp T e-3@200'and 2@100' construction to the following:
i•
10.Static water level below top of casing: 56 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection 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,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 . Method of test: air 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: 2O 67 completion of well construction to the county health department of the county
where constructed. 1
•
Form GW-I 'North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016