GW1--06506_Well Construction - GW1_20241101

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WELL CONSTRYTCTION RECORD (GW-1) For Internal Use Only:
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• 1.Well Co tractor Information: . •
'•14'�yVA1'ER:2ONE$''.'. . .. "ff,.5 :I`a:li'4.':.fw2 ::`r. . .,'r` '.`:,
Well ontiact r me FROM TO - DESCRIPTION
• ��D->A ft ft \0 ��
rj(Sft., qt ft 20 r,
NC Well Contractor Certification Number /r�'15:.OUJ ER,.G SINO:(fdr mntti=cased. `ORX,INER(if:l;P'lien.W)•:: ,":.;.4,_;
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• Morgan Well &Pump, INC p$ivp .02. C f ekp^ • FROM TO DIAMETER' THICKNESS MATERIAL '
Company Name • 4l,v[ �p I L,•+ 'a ft. 25 ft •61/8 in. sdr-21 PVC
;`16�ItvNER:O ' ING.OR:1;u13E;lG`' eotliermalclos,'ed-loo-
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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(Agricultural aMunicipa1/Public ft ft. in. '
0 Geothermal(Heating/Cooling Supply) NoResidential Water Supply(single) ft ft. in. •
D Industrial/Commercial DI Residential Water Supply(shared) ::IS'GROIIx': •:•.':".
Inigation PROM TO . MATERIAL '• :EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: a ft. 20 ft bentonite poured G.,i' m -
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DI Monitoring Recovery . ft. ft. •
- '— "•' `- ''' '•il V..:•,; l
Injection Well: ft. ft. • NO V t) 1 2024
Aquifer Recharge• El Groundwater Remediation
• .19:SANDJGRAVELTACK(if applicable)-.:..:... : :::..'•...... •-....•. - •,•
nj Aquifer Storage and Recovery ' J Salinity Barrier' FROM TO MATERIAL Il EMPLACEMENTIfErROD._.. ,,ou
• fI AquiferTest )StormwaterDrainage • ft. ft. D'I'id =_;J ".
Experimental Technology OSubsidence Control ft ft
0Geothermal(Closed Loop) [Tracer :20:.I111.1E R GLOO(attach additional'sheets-ifnecessary)':': ::.:.,;::^ ;: ::"' 'FROM TO DESCRIPTION(color,hardness,soiUrack type,grain size,etc.)
Geothermal(Heating/Cooling Retum) i Other(explain under#21 Remarks)
b ft 1S ft ,
• 4.Date Well(s)Completed:_F1 1 ' s
‘Well ID# _ 1 5 ft 3 5 ftAz.� 'r^
5a Well Location: 3S ft /_S ft. }—1i n 41 rebe-11—
VIV‘kkket.k '
CdhS agoli 65 Z.Zbft tCtsj g rash ifs.
Facility/OwnerName Facility DX/(if applicable) •
i-'t h ness .- ti r. . (!noorts K`tc.n1 e,7.81 t1 ft.
ft.
Physical Address,City,and Zip
'... r tk. g631, 3i- I to __ t . .,, . - . ,�,.,: ,.... ,-.,,... s.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22. "cation: • .
3S. (05k2 N 'a.elO W
6.Is(are)the well(s)JPermanent or Temporary Sim edw ror .
By signing t re form,I hereby certify)that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or )No with 1SA NCAC 02C.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 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 GO'ti land surface: (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 ate) 00'and 2@100) construction to the following:
10.•Static water level below top of casing: 5© (ft-) Division of Water Resourees,'Information Processing Unit, '
. ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 118 (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) 30 Method of test: air 24c.For Water Supply&Injection Welts: 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: 16z 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 Revised 2 22 2016