GW1--03860_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TODESCRIPTION
Well Contractor Name
ft ft.
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ft ft
NC Well Contractor Certification Number
...-1VQUTI R_C 1SING forwuI�cos'edwelLs ORZINER;ifs hcable E ..;.r-
Morgan Well & Pump, INC FROM TO I DIAMETER THICKNESS MATERIAL
1 ft ft 61/8 in. sdf21 pvc
Company Name _
�/� ) .161-h4NMG9SINGORTUBING "eothermsliclo'sedlo'o +�{
2.Well Construction Permit#: l/ LiZ, �/G 1 O G FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionperw s Cz.e.b7C,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: lzaGBEEN .,.:.,:w a._ s.-
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERLAL
Agricultural (�J Municipal/Public ft ft in.
J Geothermal(Heating/Coohng Supply) Residential Water Supply(single) n• ft in.
Industrial/Commercial I Residential Water Supply(shared) 318 GROUly_`?. z <r
I Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water
Supply Well: o ft PO ft bentontte poured
Monitoring ID_.',Recovery ft. ft
Injection Well:
ft ft
_'Aquifer Recharge E3Groundwater Remediation
SF19 Sz1NDIGRAVEDPi+iCS
_i Aquifer Storage and Recovery IJ Sa13Ility Barrier FROM To MATERIAL EMeLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
PExperimental Technology nJ Subsidence Control ft ft
i Geothermal(Closed Loop) ©_I(Tracer c20 DRMnNG1O:G-'aGeothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROMTO DESCRIPTION(color,hardness soil/rock a sae,ete.cc ® ft O ft. f
ft-
4.Date Well(s)Completed: V ? Well n)# o ® rG/ -F
5a.Well Location: Q ft. 3 ft. w1) &Cf'�
K �l I l (14 J 1 eT� ft ft. /M e
Facility/ caner Name Facility ID#(if applicable) ft ft
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Physical Address,City,and Zip ft ft
County ` Parcel Identification No.(PIN)
Ir',fot;a.�iCn''rcvw�vl�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: OVAIG""
(ifwell/'field,oneellat/lonng is sufficient) �J 2 22.Certlfieatio �J
1Q� N KI, 7 J� W
6.Is(are)the well(s)opermanent or OTemporary SignatukloftSertified WIM Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EI Yes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.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.
23.5ite 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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled:' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t_6 (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(2000''and 2Q100D construction to the following:
10.Static water level below top of casing: C/C/ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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:
(Le.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water SuvvIv&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: O 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