GW1--04852_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
.1'4wWATRff+ZONES'Y;:.4 . . _
FROM TO DESCRIPTION
Well C tra for Name
ft. ft.
L-71\
- ft ft
NNC Well Contractor Certification Number 1 a 5;QUTERCASING(fon mult alWiriells)OR=21VEki ftfap'hcable) ;:1- „
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. ft. 61/8 m' sd21 pvc
Company Name .
qqq p ,e,— :•.161ThiTIER,C' '}ORi TUBING(geotheihisl c1o'sed iidji) W�%
2.Well Construction Permit#: �(J 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..
:17l=SCREEN;;:;.'::: :�l.
.::.- ,-":':::in .`__ .i.; :.. ..
5ater Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
I Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft ft in.
I Industrial/CommercialResidential Water Supply(shared) , -
'18:GROUT ', . i�tl • ita
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring )Recovery ft. ft.
Injection Well: • ft. ft.
NIAquifer Recharge DGroundwater Remediation
!�
�iY9:;SAND%GItA�'EI5 PACK(ifapplieable)''-; '. ,�>'* �:��i��, 'r.��:: ems: :;;:Try .:e_.•: .
Xi Aquifer St:rage and Recovery ED Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ill i Aquifer Test ®IStormwaterDrainage ft ft.
el Experimental Technology Ell Subsidence Control ft ft. •
**Geothermal(Closed Loop) Tracer ii2elifatiOG(attsehadditionaisheetsifb'ecessary)
X Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO .{{DESCRIPTION(color,hardness,sos/rock type grain size,etc.)
(] �yb ft l a ft. ."h j t
4.Date Well(s)Completed: L 1 Well ID# IO ft 3c ft. .ddd'��ro� �iy ,J5a.Well Location: RC) ft. 'D/.5 ft. L,V P1 Chi
jyzL \p16it ftcility/Owner Name ,` Facility BM(if applicable) ft ft r%
Ilr M� ` Ct ,yCN �A(C,�a�� ' ft. "--'`a' :; lit j
sical Address,City,and Zip it ft. J l l 1 9
ral
County Parcel Identification No.(PIN) r O', per? Etr`xi!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.C••.. cation:?"---
36, N ►J0: k. 1 W
6.Is(are)the well(s)s�Permanent or Temporary Si f .fied Well Contactor Dat
1 ,
By s;'ng th• .rm,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or ®hNo 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:1 )� SUBMITTAL INSTRUCTIONS •
;6 9.Total well depth below land surface: 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 00'and 2(4)100) construction to the following:
10.Static water level below top of casing: ` . (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° Method of test: air pressure 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: \C)b 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