GW1--05695_Well Construction - GW1_20230905

.•_)10.1 Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
.„,1.Well Contractor Information: !
1 i
$14:wwTBRZONES': ::.: .: k.?: . • .
Well C tra tor Name FROM TO DESCRIPTIONI
ft ft
342z—A. ft ft
NC Well Contractor Certification Number �•
-,?`15`QiTTER;Ge1SING:(foiii"ulti=cased5v'ell's),;OIt'IaNER(ifzp hcab7e)"c'; ;t;=?.
Morgan Well &Pump, INC FROM TO DIAMETER; I THICKNESS MATERIAL
1 ft. 5 ft 61/8 ;m• sd21 pvc
Company Name - ,\ t::-: �G> ,s_:y
y1+. % �.16:INNERCe1SING:;OR T.IIBffiGeotli'ei m'sl clo`s'ed-loop) :_
2.Well Construction Permit#: FROM TO DIAMETER I 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: 17 SCREEN'_°t..i., r ws c£; ... _, _. _.-
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAT.
Agricultural ;Municipal/Public ft ft. in.
I Geothermal(Heating/Cooling Supply) t/'Residential Water Supply(single). ft ft • in
Industrial/Commercial �IResidential Water Supply(shared) .18T,GH0 ;;:. :-:Yt:
.'Irrigation FROM TO -MATERIAL uEMPL CCEMENTMETHOD&AMOUNT-
Non-Water Supply Well: p ft 20 ft bentonite poured
Monitoring Recovery ft. ft
Injection Well: •
ft ft
Aquifer Recharge )Groundwater Remediation =
t 19:SAND/GRAVED PACK(if plicable); <:":`'' :rt : :'k i= rx: e -=.:-':?:'
EtAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL ! EMPLACEMENT METHOD
*1AAquifer Test DStormwater Drainage ft ft. t►
At Experimental Technology NI Subsidence Control ft. ft. -
*Geothermal(Closed Loop) EilTracer 2651i-I TT7i GIO;G.(ittit-eli adriitional'sti'eefs°if itece"s`saiyM•4= =1:==_i:=:''.-
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DE�Sp TIO (col�or,hhard_ness,soil/rock type,grain size,eta)
P� ft. kC ft. r r_- lJ L1
4.Date Well(s)Completed: Well m# L. ft '2S ft. . Yao�p 14.
rell Location: ,, r D �� -3 J ft e� ft is, ,\K l(^p�/-
1 0b ft lf'=�i ft yeTe_ esai^J,v1,,
ras �V1 • '�~ - ft. `1GJ�.+' ft W 1!- �. -r..
Fac gv2 erN e Fn. ty ID#(if applicable) C.a.� -p; rl
\kA.T•+�=>• (� t•.J 6 Ici✓ "'ft. ft
ys al Address,City,and Zip .Zrtl"" ` 1 ft. f t -: . S E P a 5 7023 .�� ,k ` y211.iREMARK.C;'i:.: , -. ',. ..'.i.,;gf'-rr''5.;a::`._l,:'1. 't_,t
CountyParcel cation No.(PII� ink,rn.etiun r f.^Cz5;1 +.f.1(UF1il
L.W,A.ltV, .-1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,
,00ne
e'laatt/long is sufficient) /'� W161
22.C • cation:-6lC�i tJ)r) N �,J, W 27 Sigoa f .ed Well Contractor_2 '.
D e
6.Is(are)the well(s)+11Permanent or Temporary i',
By s mg thf.rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or igrNo with 15A NCAC 02C.0100 or ISA 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 e SUBM TTAL INSTRUCTIONS I
�` I
9.Total well depth below land surface: l,[� (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@1001 construction to the following:
10.Static water level below to of casing:
g: J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
I '
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:
(ie,auger,rotary,cable,direct push,etc.)
- Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,I'Raleigh,NC 27699-1636
13a.Yield(gpm) .--)DC. Methodpressure 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
Method of test:
the address(es) above, also submit one I copy of this form within 30 days of
granulated chlorineL completion of well construction to the couptY health de artment of the county
13b.Disinfection type: Amount: (� P P
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016