GW1--06519_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only:
�atractor Info moltion: .. ,. .- . ._ .. .. .. ,,.-3:....,
.
L O �i( ::14.WATE�t✓LONES:, „': iF.•.,i`:, ;"i°'"t%:" �.::t•;,,17 :'
Well Con et *Name FROM TO ~SCRIPTION I`l
4- n ft ft I
7/�\ 1 ft. ft
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NC Well Contractor Certification Number d5;.0U'ZER;6AMNG'(fdr multi,Cti ed well's)311XOLER:(Mini'licabJe)•:_`:,ti:%v;:.`•:.•:;>:;
Morgan Well&Pump, INC • FROM TO DIAMETER; THICKNESS MATERIAL '
Compahy Name 0 ft ll ft •6118 fin. sdr-21 PVC
;16:•IIVNERiC .OR>lu.10:9•; eotliermalelos.'ed-lou :v::;*
`� kc'l.c•k°l (g p)'::::•MATERIAL
2.Well Construction Permit#: L{\. FTtOM TO DTAI+�1aH THICKNESS MATERIAL
List all applicable well construction penults e.UIC,County,State,Variance,etc.) ft ft. in.
. 3.Well Use(check well use): ft ft. in.
Water Supply Well: rX7:HCEiFEN:v:';:s:.'::.:a:•: Zx '• =..; :<.,. .' '. :+:::: 'f:•<••,: .h. ,.y, ,..
FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
X Agricultural DMunicipal/Public ft ft. in. •
X Geothermal(Heating/Cooling Supply) iStResidential Water Supply(single)
ft ft. in.
X Industrial/Commercial Residential Water Supply(shared) :,.:, • : .•. .. .: ,.. :.;
I Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&AMODNT
Non-Water Supply Well: o ft 20 ft.: bentonite • poured
X Monitoring EiRecovery ft. ft. •
Injection Well:
�-�{ ft. . ft.
MI Aquifer Recharge !�1 Groundwater Remediation :ly.sANIi/t'>RAVEL PACIZ(if applicable).:• • :.. ' • •
igi Aquifer Storage and Recovery 0 Sal inityDenier FROM TO MATERIAL .•.EMPLACEMENTM•ETHOD ~' •.
IJ Aquifer Test a Stonnwater Drainage ft ft. '
t Experimental Technology D Subsidence Control ft. ft. '
II Geothermal(Closed Loop) OTracer .20:.DRT]GL•iN-GT.ot:(atroth=addi4biism1ieets'r1'necessa y)'::.. ' r::::;1.r•-:..: :,'•":;
Geothermal(Heating/Cooling Return) 1'i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain sae,etc.)
6 ft" 55 ft. V,, .IlN(A, .
4.Date Wells)Completed:`t) i tLl Well ID# 55 ft 5• ft b r t h •roc-k•
5 Well Location: 14 ft C ft \U't l.'�i -- -ft. ft.
AINSA
Facility/O ame Facility ID#(if applicable) ft ft. I NOVft ft. V V :i 2)24
. .
Physical Address,City,and Zip ft ft. 1L.........,.' '77 -'- ei
County u Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•(if well field,one lat/long is sufficient) 22.Cer' cation:
35r i N /TO13596 W (a I.a'S tit
6.Is(are)the well(s)JPermanent or EDTemporary Sigrra Ce ' ed Well Contractor Date `
• By s d ring this orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or jNo with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Pell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain Aye 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 Jane.
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:' y� . SUBMITTAL INSTRUCTIONS '
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9.Total well depth below land surface: !21) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'and 2Qa 100`) construction to the following:
10.Static water level below top of casing: e3 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6118 (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,directpush,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,IRaleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air 24c.For Water Supply&Infection Wells: In addition to sending the form to'
. the address(es) above, also submit one Icdpy of this form within 30 days of
granulated chlorine
13b.Disinfection type: Amount: • (j7J 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