GW1--04175_Well Construction - GW1_20230706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
TA �odrl —3 /,
WellFROM TO DESCRIPTION
Contractor Name
, ft ft
LI5c4.. 15:OUTER:CASING.foiatiltt.cased:vr�
it ft.
NC Well Contractor Certification Number __
( e']Is)ORIsIl1'ER,(ttap-hcable)_,� ._.
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft 1.4 ft 61/8 in' sd21 pvc
Company Name V/
( (6i1 �I6EINNF CCASING:Olt:TUBING.(keotlieiiiitiaiss"edlodp7- __.a�.:- ._.
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): ft ft in.
Water Supply Well: ', 'O GREEN TO 'V DIAMETER <,
FROM
RR SLOT SIZE THICKNESS MATERIAL
Li Agricultural J Municipa1/Public ft. in.
J Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft' ft. in.
Industrial/Commercial Residential Water Supply(shared)
IILigation 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 1 Groundwater Remediation
.19'rSAND/GRAVEI-T.g.0(i£applicable) - _'
IlIAquifer Storage and Recovery EllSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test EllStormwaterDrainage ft. ft.
*Experimental Technology QlSubsidence Control ft. ft.
•Geothermal(Closed Loop) DITracer '°20MI II:DINGLO,G(attacli addifibiiiits`heetsif:necessary) ~
FROM TO DESCRIPTION(co or,hardness,soil/rock type,grain size,etc.)
1 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O it. O ft. ��1 ] '
G (?t
4.Date Well(s)Completed: 5'3a'Z3 Well ID# 0 ft Ol ft lb row" citoc, .
5a.Well Location: 5 I ft bS ft 13 l lA (6"' '
� TT i .v ;i !1 / 4: 7.
ft
Facility/Owner Name/y A _/ ]Facility ID#(if applicable) n
,/t, !/ ie, ,i .�f ft ft Il ll �'• 21,2J
Physical Address,City,
aannj•./Lip//� / ft. ft ^,y i ice„
• SV j46 1 :21 T2Elj ARTCCri. ft., q.-_ > .._.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce •
35,73/ti7 N ga'553Z W <7-2-3
6.Is(are)the well(s) permanent or ®*Temporary Si e of citified ell Con ctor ate
X)
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: )Yes orONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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#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:' / 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 0'and 2@100') construction to the following:
10.Static water level below top of casing: a( (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 Injection 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) 3(9 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
c the address(es) above, also submit-one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: J D Z 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