GW1--06540_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only:
tractor Info nation:
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:44:59ATER1'ONES`:,:i:i• r- r_ . ...
Well Cost(� ct -Name FROM TO DESCRIPTION i
3 1 -A AG ft Art ft 1y`4NC Well Contractor Certification Number ft �2 Q ft ljt !.OUTER;C• IINN4.(fdrin11..)..4
llti' kdwells)OR.Xakn Ie.gip'ricatile):,.`•;:i:%,;.`•::.v':,
• Morgan Well&Pump, INC- • FROM TO DIAMETER' TBICI{NESS MATERIAL '
CompabyName a ft 4 ft •61/8 n' sdr-21 PVC
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11L_ .':Id•I�`INEItiC4SING,Q16 IIBIIVG.,rgeell ermal closed-loo
2.Well Construction Permit#: FROM • TO DIAMETER TDICIINESS MATERIAL
List all applicable well sonstruction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
•
' 3.Well Use(check well use): ft ft. in.
Water Supply Well:
s17:xSG'I�SiN.r•:::tt:.;::• ';:.7%ti,.•' 'i: = >.::v'.::::'::°' ^, :::;:
FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
1 Agricultural 0Municipal/Public ft ft, in.
BJ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. . in.
II Industrial/Commercial Residential Water Supply(shared) :'I8 GR017T ,.' :,: :;. :•..
Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&_AMOUNT
Non-Water Supply Well: o ft 20 ft.: bentonite • poured
•
II Monitoring DRecovery ft ft
Injection Well: ft . ft.
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I Aquifer Recharge Groundwater Remediation 19_SANK/GRe1VEL•PACK rut a cable '
C PPh• )•�
*Aquifer Storage and Recovery 0 Sal in ity Barrier FROM To MATERIAL EMPLACEMENT METHOD
•
A Aquifer Test a Stormwater Drainage ft ft
*Experimental Technology 0Subsidence Control ft. ft.
MI Geothermal(Closed Loop) r3Tracer •20:.DRlL.11I((•LOG`WtddliatiditiO01.shedts ifnecess
FROM TO eESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
■ Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks)
/A/ O ft .�� ft- row�•,, 4,-,(-- - .
4.Date Well(s)Completed:`O/ ill,t Well)D# t b ft. S it b rifwh .row k.
a.well Location: L . . . 'I; ft. Lint,ft '{rue' ()min t,4(, •
' � tJ ft. ft.
J` ,I t r ,
Facility weer ame Facility ID#(if applicable) ,
ft. ft. i a. a t.y 6.. •/ d._, �.
,1 ft ft. NOV .) 4. 7074
Physical Address,City,and Zip ft ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
,(if well field,one lat/long is sufficient)
3�� ���_ �j (�,, 22.Cer• canon:
-TCE+.��=�' N $b "3 1 1O W b
italcn
6.Is(are)the well(s)JPermanent or Temporary Sign Ce ed Well Contractor Date
By ing this orm,I hereby certify that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or EINo with 15A NCAC 02C.0100 or ISA NCAC 01C.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 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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below 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@200 and 2Qa 100') construction to the following:
10.Static water Ievel below top of casing: 2.0 (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 farm 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,i Raleigh,NC 27699-1636
i
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
granulated chlorine
13b.Disinfection type: Amount: ,1.7 T',
, completion of well construction to the county health department of the county
where constructed. •
Farm OW-1 North Carolina Department of Environmental Quality-Imivision of Water Resources 1 Revised 2 22 2016
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