GW1--06536_Well Construction - GW1_20241104

i
WELL CONSTRUCTION RECORD (GW-1' - For Internal Use Only: •
Cb rtractor Info mattion:11.
I
L (� �i(� • •:,4 WA.11AtvLONE •'.. �.0a.,;1.,:.i.:"d:;;•,.w t: tr.-:•):.:. •.x:• ,. _ ..:
•
Well Cont ct 'Name '
FROM TO DESCRIPTION r�- •�`•• ~
4 'A , ft )1�ft //1�� -
ft. / ft c/A`/`� i
NC Well Contractor Certification Number ;I,S;,p .G¢SING'(fdrmniti•-caged well)'OR LIVER:gap'IjcatiJe)•:;.':1 id*.:: •
• Morgan Well&Pump, INC • FROM 4:11, DIAMETER THICKNESS MATERIAL •
•
CompahyName p ft. ft 'fi 11fi m. sdr-21 PVC
a
��� i16.7i,VNFd2iCA'SING:,0�2%TIIBI17o:(getliecmalclos'ed-loo��::�•..� ;.::",.':`',i,�;..`;;;':;.;' t-
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): y{p/�pf�tp�} ft` in.
•M-4,,LEBEF.'.1:.•..•Y:. :..t:: ,•S.i.::..n:v:.N.'.'.:'.ti:;::.. .::`:.C.T;'f.'..±.•.::
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
El Agricultural 0Municipal/Public ft. ft. in.
M Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
II Industrial/Commercial JResidential Water Supply(shared) :.Isz GROUT r`•. ':, ': °:'•:: >•;': ;: :" .:.: `:,
L Irrigation • FROM •TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
Non-Water Supply Well: o ft- 20 ft.: bentonite • poured
}Monitoring EIRecovery ft. ft. •
Injection Well: ft. . ft
Aquifer Recharge Groundwater Remediation I9_s / A�(if appti�ble)'._ :.. "
Aquifer Storage and Recovery Salinity Barrier Stor FROM TO MATERIAL - EMPLACEMENT METHOD
Aquifer Test mwater Drainage ft Ft
Experimental TechnologySubsidence Control ft. ft
Geothermal(Closed Loop) Tracer .ZO:.DI I L73VGLCG:(aftacl additionaI'sheets ifncces'sa y `''
FROM TO ESCRIPTION color,hardness,soil/rock the,etc.)
Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) ft ft t hie.Mtn
4.Date Well(s)Completed: I' >1„:24 Well ID# 5 ft SS . ft b II'A�� •ram k
Sa.Well Location: ' . • 35 ft. i . ft. +{is Cy 1_1.bc,
ft. ft
-4PX L
Facility/OwnerName Facility ID#(if applicable) ft ft. ki-..`,,,, '_ Y /' n•
•
Physical Address,City,and Zip
ft ft. NOV 4 2024
fi din >it031 -.,.... .. ., . . , . . •``°,._...:-.` , --• .• . •- ....
County Parcel Identification No.(PIN) L° :.i;. i.:,,3i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
`,(if well field,one latfong is sufficient) (� 22.Cer' cation: �A '
`n J cJ N 1�� �7 w C��L�
6.Is(are)the well(s)JPermanent or Temporary Siena Ce ed Well Contractor •
Date
i
By 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 EiNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200/Yell 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 1121 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 land surface: /Os (ft-) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths if different(example-3 a00'and 2@a 100) construction to the following: j
s1
10.Static water level below top of casing: tT 5 (ft) Division of Water Resources Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 i/$ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy of this foam within 30 days of completion of well
12.Well construction method: construction to the following: r
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,IRaleigh,NC 27699-1636
13a.Yield(gpm) I V Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to•
granulated chlorine Q� . the address(es) above, also submit one I copy of this form within 30 days of
13b.Disinfection type: Amount: . completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources 1 Revised 2-22-2016