GW1--05707_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
WellOM TO DESCRIPTION
C t[a torName
ci5ft left 0 (II
3 -A ft ft I IV
NC Well Contractor Certification Number ,• 4.. - (•-•-- -t ti r . r,-,-;.,;;,�:
,;.T5:,O1:lTER CASING'fat'multcased`wells)OR+L2NER(rf'sp"Ircfib7e)c�i�, � .ch`'�?:.
Morgan Well &Pump, INC FROM DIAMETER THICKNESS MATEERIAT
1 ft ft. 61/8 ' in* sdr21 pvc
Company Name . 41.64. .,,
( llF:163' ILVER:Ge1gING°,ORTQBING(e`a'th`eimaFclose3loop�:O e_ - =:ar.e - .,2.Well Construction Permit#: 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.
17:*SCREENS _::': `c. -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
$1 Agricultural DMunicipal/Public ft ft. in. .
II Geothermal(Heating/Cooling Supply) v jiResidential Water Supply(single) ft ft. in.
*'Induslrial/Commercial Residential Water Supply(shared) :.LS?GRO . ;._ •_-- - - --. - _ - .
r !IIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft bentonite , poured
•IMonitoring DRecovery ft ft.
Injection Well:
•Groundwater Remediation ft ft.
fig Aquifer Recharge „
`�c19:SAND/QtAVEIEACK(ifapplirable)'.'::�':".;::: . 'k=:;)-*1r`,-s`.•i4:`'.1:-.'=?'::` rir•,
$iAquifeI Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD` `
•IAquiferTest DIStormwaterDrainage ft ft
go Experimental Technology *Subsidence Control ft. ft ' •
RI Geothermal(Closed Loop) ®I Tracer (:20`DOING'LO;G:(attscc ad'ditiiiii shalt's'if necessary) ' it^sue-^'.. >',':'_`:`
Geothermal(Heating/Cooling Return) �J I Other(explain under#21 Remarks) FROM TO DES o (color, artiness,soil/rock type,grain size,etc.)
ill e,ft ft. Y-ai (. \
Well(s) P ``' liS ft ` ft. rtJIN' ',lll..,,,kkkv .
4.Date Com leted: t t ell ID#
5a.Well Location: ft ft 1�
V1� OC �l' GJ ft t o_2. l l \ (J 41
g ft. ft.
Fac1cility/,Owner Nie � Facility ID#(if applicable)
4 et;J i✓p ' tl� 2 \vs )i.L, ft. ft
r•-•. . }
ft ft f 3 C L 4 Aim r3/4t
al Address,City,an Zip U} a n r r
.f 1 12t-att.1VfAY2KR;C.;r".,;r:=.,:-`.o' *'' ..':: a sK_';:.: •,,,•�v::,:f-.., ,,„ .:i:/.i:zr 2::;
County . Parcel Identification No.(PIN) D 4023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Illforcr.8ilr'Z ry;
(if wellldeld, n laat/�long' sufficient) 22.C ' cation: DeVeu_P L',.2 im,$
6.Is(are)the well(s) Permanent or OTemporaly Sigoa f • ed Well Contractor Da
By s mg th rm,I hereby cer ,that the i5 well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D1 Yes or ®FNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
' If this is a repair,fill out brown 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:' tc)e SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (a') 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(erent(example-3@„200'and 2Qa 100) construction to the following: 1
10.Static water level below top of casing: D (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 Infection 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: 1
(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,a NC 27699-1636
air pressure 24c.For Water Supply&Injection We lls: In addition to sendingthe form to
13a.Yield(gpm) Method of test:
the address(es) above, also submit one`copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: �' completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016