GW1--04838_Well Construction - GW1_20230728

• P�lifForm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use.Only:
1.We l Contractor Information: .
..ii14 WATERZONES'a,..-,._, _ _-. - . ,_.:-.. .. _ ,- _'.. _.•
Well C tra tor Name FROM TO DESCRIPTION
3� ft ft
'A ft ft I
NC Well.Contractor Certification Number ti.:d.
c1:5i:OLTTEIt':CAS I (fgr:;miiliaised_Wells:ORLIIVER tf^i- licable -:g.33.31.—.:,
Morgan Well &Pump, INC p RIAL :•
FROM TO DIAMETER THICKNESS MA'rF.urar.
1 ft 4�'1 i ft 61/8 m• sd21 pvc
Company Name • 7.-, ;.III. . l - --...---a-�., ... ,IaIgi'=._.:::; :a
^1" /,"�J,�yJ�}�.}.�� .:,16`JNN RGASING;ORJ u3IF G(gelH`ereu l_clo3e3;loop7. } - :..�.
2.Well Construction Permit#e `� •,; "c '� • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Coun),,State,Variance,eta) ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: REEPLf_' ;._ ': ;.__. _U_.s:Y_ .w �_- ik;-
FROM TO - DIAMETER SLOT SIZE y THICKNESS MATERIAL
I Agricultural IMunicipal/Public ft ft in.
I I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in
_1 Industrial/Commercial �IResidential Water Supply(shared) 8`'GRti - r,.;- _ ,• ' ,
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring LJRecovery ft. ft.
Injection Well:
ft ft.
I-_'Aquifer Recharge O Groundwater Remediation
19.SAND/GRAV.ELLPACK(if`ip sbt8ble)': ,,.;.::i<.___- :- -.i'''. : _.:;-"
L Aquifer Storage and Recovery IJ SalinityBater FROM • TO MATERIAL EMPLACEMENT METHOD •
Aquifer Test JStormwaterDrainage ft ft.
D Experimental Technology .QlSubsidence Control ft. .ft •
I _Geothermal(Closed Loop) 0Tracer 20 b12II7 iNGT:O,G(AttaelCid"ditielainlie'ets"Sfnecessary):a�35:L_'.-' <r>"r ,=
L.''Geothermal(Heating/Cooling Return) �1 Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
7 C) ft 1� ft. red ]et
4.Date Well(s)Completed r [tota.j Well ID# iD ft ` ft '�xlju(r� 4i
Well L a on: • '� ft. 55 ft. ID re - -f4r,tc
•
< Y A 6,I` 5 5- ft. ft
Facility/Owner Name Facility ID#(if applicable) O ft 9 t,ft b cto l^ r E
�5� Fa• )V\.()V !jCG 2 e lc'j ft. 4_ciS ft t�.rn .
Physical
ical Address,City,and Zip �' r a ,
Y ��/ ft ft k`! M .' f L,i
�" 7 ll. •
i21':RF.M../.. .":, _,.- :-. ..&. ....,,',:77;f4..,. -:.' ,,..r :ie
County . Parcel Identification No.(PIN) JUL 2 82023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �,,, :? a� ,
Infcs- :i t ,,..., i.. l:r, :
(if well field,one lat/long is sufficient) 22.C ' cation:
t� q)j9 G!}+`emu '
cJ a� �� N Vll, W !7 ,
6.Is(are)the well(s);;Permanent or ©l(Temporary Signa.. f fied Well Contractor Date
,a P
By s,,,"ng rh rm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well:',Yes or ligNo with 15A NCAC 02C.0100 or 1SA 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:' t , SUBMITTAL INSTRUCTIONS
•9.Total well depth below land surface: L.. l.! 1 •
(ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@,200'and 2@100' - construction to the following:
10.Static water level below top of casing: V • • '(I) 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 m. ^:•.
( ) )�, 2411?.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 27 69 9-1 63 6
ai
r pressure 24c.For Water Supply&Injection Wells: In addition to sending Yield(gpm) 5 Method of test: the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount .7O� completion of well construction to the county health department of the county
Il where constructed)
Form GW-1 North Carolina Department of Environmental Quality-Division If Water Resources Revised 2-22-2016