GW1--04900_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
14:14?-WATER>$ONES'. •t' s"r'i :'" .E
Well C tra tor Name FROM TO DESCRIPTION
34 ft ft.
L.�. ft ft.
NC Well Contractor Certification Number
15,01)TERCASRIG.(famulticsse'd=we11#01211NEIt"ft ip licab`le) 7 -;;'`:.
Morgan Well & Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
e 1 ft. j�� ft. 61/8 in. sdr21 pvc
Co
mpany . l -
. TRJ—W5. 16 INNER CASING`,O. K,TUBING;(geotfiermal`close-d'3uop) - { ....7-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction permits(i.ety State,Variance,etc.) 'ft ft in.
3.Well Use(check well use): ft ft In
s,17 SCREEN"' _ Z"..,.:.: n'-.,.. :'`,: .;.._;.emu>:_f:-.'l:' ,,,:-.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ;;AlResidential Water Supply(single) ft ft in.
0Industrial/Commercial . DResidential Water Supply(shared) �
nlIrrlgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
DMonitoring DJ Recovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge 0Groundwater Remediation
+'].9::SAND/GRAVEITPACK(ifapp7icable) ;i; _
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ir i Aquifer Test DStormwater Drainage ft ft
MI Experimental Technology 0Subsidence Control ft. ft. •
*Geothermal(Closed Loop) OTracer s`26 DRItINGI,O,G�(attach'ad'drtiona''slkeebifniaiisary) „.3 1` `;
II Geothermal(Heating/CoolingClose Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type Brain size etc.)
i -t) ft. 18 ft. . \ �.,
4.Date Well(s)Completedi 7 I 1 Well ID# )S it
C]sJ ft 71 r`, Alt4 . .
5a.Well Location: { I- ' ft. 70 ff-. 1-0 Wt, .York
c 'S f]a ft. $5 ft. Sul('+' I V t.,cc.Y1
Facility/Ownerci`y Name a ,,,i Facility ID#(if applicable)
` e �,$ �(ft ,vac f. .L i 11.-Yy
\C/ 1 }\ ' t-* Cjl r de \4`j-� 1 V la N� V'+"' 1t 30 ft. �1u� Iwhi
Ph •
sical Address,City,and Zip ft. l� ft _ y {
�� oct3 t;21 REMARKS . s:s_... .er- ,� �. `':: __
County . Parcel Identification No.(PIN) J I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lJ L 2023
(if well field,,onfeellaCtlllong is sufficient) �jt� 22.C • cation:
Jj'`' ! i 1 (��J r."2 klfc�';r.�zni f'Ir•c. g l:nx
N i 616:3 W. G`1°1�1' 1wa t,
6.Is(are)the well(s) ;Permanent or DTemporary Signal led Well Contractor Date
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By s e mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or +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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C :"-') (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'and 2@.100) construction to the following:
10.Static water level below top of casing: 7 (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
air•
pressure24c.For Water Supply&Injection Wells: In addition to sending Yield(gpm) � Method of test: the form to
the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine
13b.Disinfection type: Amount: f57...- completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016