GW1--06492_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW 1) - For Internal Use Only: •
ed,.tractorma11tion:
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i n c ,A, .
Well Cont ct •Name 1FrROM TO^ D~`CRIPTION,h r.. .=?
165• ft 1("l `ft ew-.
�� • +1`6 ft ft l�Q.
NC Well Contractor Certification Number • 15s.0 U'iH.R;G " '"•h spe `(forma('• ''d iveICs}'ORT:Olt(if a AcaliTe).;'•';:r•:`:,:a:,
- Morgan Well&Pump, INC • FROM TO DIAMETER' , THICKNESS MATERIAL •
CompauyName 0 ft ft •6116 in' sdr-21 PVC
lt%•Il_VNERiCA$ OgIECBING; eo•tliei;nialclosed-Ioo „':':-,'.:',•s-,:;•:. ,
2.Well Construction Permit#: gril' FROM • TO DIAMETER•. THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC, ow State,Variance,etc.) ft ft in.
' 3.Well Use(check well use): ft it. ;in.
Water Supply Well:
FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL
I Agricultural 3Municipal/Public ft. ft. in.
X Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft ft in.
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ii Industrial/Commercial - EResidential Water Supply(shared) :•I8 GROUT •.'..:,i: ..
X Irri:ation FROM •TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - o ft 20 ft*: bentonite - poured
X Monitoring DRecovery ft. ft. •
Injection Well: ,
ft. . ft.
X Aquifer Recharge DGroundwaterRemediation :19:9t1NU/GReiyELPACTC(if aPhcahIe)iiAquifer Storage and Recovery0Salinit Barrier FROM TO MATERIAL
; FeIIPLACEMENT METHOD
X Aquifer Test 0Stormwater Drainage ft ft.
i Experimental Technology 0 Subsidence Control ft. ft. •
X Geothermal(Closed Loop) DTracer 20 DIULL1NGLOG(attach additional sheets ifuecessary)'
Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrack type brain size etc.)
x ft 2.6- ft by-0,1•,v, 1
4.Date Well(s)Complete/ Well ID#OIXO
oZ� ft- 40. ft b r v' '{ c-k -
5a.Well Lotion• . • b ft t�© ft 1 IU'. �f pT y
whiff
ft ft. iI.
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Facility/Owner Name fl Facility ID#(if applicable) i p e. ;:
/ ij,l ? d a.1 � NC 2 4) Nov 4 ;02ysical Address,City, Zip •
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.(if well field,one lat/long is sufficient) , 1 22.Cet " cation:
5, 4195 !0 N .'i2—�3 W ;� to �_t r
6.Is(are)the well(s)JPermanent or Temporary Siva Ce ed Well Contractor D e
- By ing This orm,I hereby certify that the weIl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fI Yes or EiNo with 1SA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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 Geeprabe/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:' '� y� •
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �)v"v (fh) 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:
10.Static water level below top of casing: 3S -(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 ito'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.) 0
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel-,Raleigh,NC 27699-1636
13a.Yield(gpm) 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: —)...or2, completion of well construction to the county health department of the county
- where constructed. 1
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources C Revised 2 22 2016