GW1--06541_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only: is •
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tractor Info mattion:
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` (�AA -:;X4.:.VJATF1itONEg:.,.. .. x.�;;i. ::3. °':.. , %r,•`.:: 't'.:'t.;:.; '.<}...,
FROM TO DESCRIPTION! r�.:
Well Con ct Name •
1 I` f
34J� 1'tS ft l��n ft �(a cc]a_ �G � oh
ft ft.
NC Well Contractor Certification Number • 15:.OUZEI1:;CASIN4'(frfij ilt i iced.ii.ell's)•ORX, iER:(iLap IiiiihJe):t:•;:i:/1 :I>-';::
- Morgan Well&Pump, INC • FROM TO DIAMETER' ' THICKNESS MATERIAL •
0 ft ft -61/8 In' sdr-21 PVC
Company Name .1 A .1e.I1`lNEktiCAS G:,O D.1111VG;(geotlie�alclos'ed-lobe) :[::,':..;;::;.'.:,,?: ..`;` _
2.Well Construction Permit II: l FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft. in.
• 3.Well Use(check well use): ft ft in.
'iI7:BCR'.ElN:<,:••:x:. :?:•':.:,.�:'..'.::.:::..,::=:.?7.;.�`.::•:•_:,a....... ..... .. .3,,
Water Supply Well: :.�:•::.<•a. :. :.:::::':::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural 0Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) MiResidential Water Supply(single) ft ft. _ in.
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X Industrial/Commercial DResidenfial Water Supply(shared) :.18 GROUT•:; ' v • .•.`•
I Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - a ft Z0 ft: bentonite poured
X Monitoring DRecovery ft. ft.
Injection Well:
ft. . ft. '
X Aquifer Recharge D Groundwater Remediation .
:19.SAND/GRA.VEL PACK(it applicable)•.:• .:.: • .. ' '
*Aquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL' EMPLACEMENT METHOD
J Aquifer Test DStormwater Drainage ft. ' ft
g Experimental Technology 0 Subsidence Control ft. ft.
X Geothermal(Closed Loop) DiTracer .20:.DRILTi1\10I,OG:(aftacli=additibriiI•sliedis'rTneeaSrify7 1"•"
FROM TO ESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O
` ft . 5 ft r0�t+i, A
4.Date Well(s)Completed: �gI�- Well 5 ft %�S ft �f��h ,Y'��i
5a.Well Location: 111 (. • • • 35 ft Oa)ft' 1\U't.61I�/''1F'M"'W o .L'G•c•. .--7..'.'-..' ; 1 , {-7.
A ' ,' ft ft J t•.ar 'a. ':v.�. , + ?.: .n S,.i.
Facility/Owner Name Facility ID#(if applicable) R N O V 0 4 Z]Z4
Lt. -Vic OW VYlorovc.(1c {4v mil• kI KC-Zglri'. ft -2:•:i.'3'..;:-.'-2"
Physical Address,City,and Zip ft ft. a ✓r
L
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.(if well field,one 1st/long is sufficient) 22.Ce ' cation:
3 •CSS`t. N 10,(33 --- W i lAISIlf
6.Is(are)the well(s)JPermanent or Temporary Sidra Ce ed Well Contractor Dab
- By leg this orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Di Yes or EINo with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
• repair under MI 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:1 . SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: t) • (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example- and 2@.100) construction to the following:
10.Static water level below top of casing: v (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
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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 SUPPL+Y WELLS ONLY: 1636 Mail Service Centf r,iRaleigh,NC 27699-1636
13a.Yield(gpm) 3 I-. 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: ��O �Z" completion of well construction to the county health department of the county
where constructed. 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016