GW1--03896_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information'
FROM I TO I DESCRIPTION
Well Contractor Name
J J 5-� A ft. ft.
ft. ft.
NC Well Contractor Certification Number
'15:ODTER:CASINQ:for'iriiiltl?rseedivells'ORATNER ifh.'Ileahle"z;:�•"`:.;: ';::t=::, I
Morgan Well&Pump, INC FROM To DIAMETER THICM4ESs NA1EunL
1 ft, ft 6118 sd21 pvc
Company Name -
�������_ I �]�n/ r16:'TNNER`CASING'ORTi7BICiG` 'e'u'tltetmsl.clusedl6o' _�Cr�4... ;.'• �:'•:•:,
2.Well Construction Permith. .ML +2-0!G ��U,.• FROM To DIAMETER TMCICJESs MATERIAL
List ail applicable mvell construction permits(l.e.UIC,County,Slate,Variance,etc,) ft ft. in.
3.Well Use(check well use): ft ft, in.
Water Supply Well:
:17:SCREEN:�;_'.;`i:::'ia:';'•.::;';'==a=;•:�1; y,:,:=•:::,,::.e,_ :=:,:::.:._:.,;:;< -<:;,.r:v;-
PP Y FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL i
_I Agricultural DMunicipaMblic it. ft.
Geothermal(Eeating/Cooling Supply) PResidential Water Supply(single) it, ft. in•
I
IndustriaVCommercial OIResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLAMIENTMRTSOD&AMOUNT I,
Non-Water Supply Well: 0 ft. PO ft' bentonlle poutad 1
—Monitoring E3Recovery ft. ft.
Injection Well: it. fL i
_'Aquifer Recharge [3Groundwater Remediation
Aquifer Storage and Recovery �SalinityBamer FROM TO MATERIAL EMPLACEMENT'hIETHOD i
3.Aquifer Test K3StomrwaterDrainage ft. ft.
ExperimentalTechnology l3Subsidence Control ft. ft.
Geothermal(Closed Loop) EpTracer 120:DRILLING1OG:ntta'ch'adilltloiial`d}reetsfaecessa"
—')Geothermal(Reating/Cooling Retain) ' Other(explain under#21 Remarks) FRO
cc) Pr
M To DEscR>prloN(color,hardness,roiUrocx sue,ere.
it ft. d
4,Date Well(s)Completed: Well ID# it 0
Sa.Well Location: ft. it. Q�� {
I J - f ft. rc e
Facility/Owner Name /� I 1 Facility ID#(if opplicable) ft. ft.
_4140 �ea 1��/�V y,L':V' ` t"i �1��lU (J it. ft. I
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: I it [l I
(ifwell field,one lat/long is sufficient) 22.Certification: l(
W won Prix VIfol
• ur of Certified Well• ontractor � — i
6.Is(are)the well(s)OPermanent or Temporary Signat Date
By signing this form,I hereby certify that the mvell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or XO:No adth ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knohvn well construction infornutfion and explain the nature of tie copy of this record has been provided to the well owner.
repair under i121 remarks section or on the back ofthis 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 ifnecessary.
drilled:r . // SUBMITTAL INSTRUCTIONS
!
9.Total well depth below land surface: 6 5 —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdierent(example-3@2000'and 2@100) construction to the following:
10.Static water level below top of casing: ` (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 (in.) 24b.For Infection 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,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ZP Method of test: air pressure 24c,For Water Supply&Injection Wells: In addition to sending the form to
r 7 r.� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount I a'D completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental quality-Division of WaterResources Revised 2-22-2016