GW1--04864_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well/fe tractor Information:
v4\I 1Ocb 4e- kt4 weTERzzo& r .ii_xr ,.:-::K _. . . , _ .. -
FROM TO DESCRIPTION
Well Contractor Name �Q ft. ft.
1gcJ ^ / ' ft ft
NC Well Contractor Certification Number 4 a
1$.OII'1�L�R CASING(foi•multi cap"`edl`vPe]ls)OR�IINER:(ifap`hcable)Y�:O , -
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft q / ft 61/8 in* sd21 pvc
Company Name e [/- t,1'6s;INNEWC IA:SIN�`G'OR 1,IB 7G(iailiermal close3-16-6)$I r t .: . "a
2.Well Construction Permit#: OV W(L(Q�:.�� IL7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UICC,'County,State,Variance,etc.) (V ft r2.O ft. q in.
3.Well Use(check well use): ft ft. in.
Water Supply1 Well: `17SCREEN`, .�.� _ ., kr�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural �MunicipaUPubliaterc. ft ft in.
I Geothermal(Heating/Cooling Supply) ii;(IiResidential Water Supply(single) ft ft, in.
__IIndustrial/Commercial Residential W Supply(shared) a18GRO.UT "_n _,< r,At,,,_E ._.. a <.=.
�I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft Y0 ft ' bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft.
1.._I Aquifer Recharge )Groundwater Remediation
^19:.SA DIGR&>VELYACS if a hcahile
C PPS )r.-v:��:�.
I
Aquifer Storage and Recovery ®J Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test XI Stormwater Drainage ft ft
Experimental Technology Subsidence Control rt ft.
Geothermal(Closed Loop) Tracer `20 pItII LINGO O.G attach:addrhonaI sheetsitneceasa Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,Praia size,etc.)
O ft q f) ft. 9-C CI ill
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4.Date Well(s)Completed: —2` [ 7- Well ID# CIO ft ? ft Mown�7 G),c
.5a.Well Location: 7 ft //._L ft rJ lV, L��/•1&'
P e, bU l 1 n ri-4Mp61 ft
�/ ft
�vJ(�
Facility/Owner Name Facility ID#(if applicable) it ft Z,
ZgC) 61\16lr{/� d( ft ft JUJL 2 :32023
Physical Address,City,and Zi
` r �(i 21�RE1VIs-i 4 .,-.:.x„ r'rsa f "'__'aliiti f 1, m =^v 3 aa�T.)rt i
�-! DWO
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is7ffi sufficient) 22.Certification:
(555.7 1v�[_ N �`J- c/7,3 w 7 ' -13
6.Is(are)the well(s)JJx Permanent or Temporary Si tore of citified Well 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: DYes or XI No 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:' l r� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( l9 ) (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@200' d 2@100) construction to the following:
10.Static water level below top of casing: 10 (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 2 7 69 9-1 63 6
13a.Yield(gpm) 5.0 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: 6 •'j OZ 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