GW1--05708_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.We Contractor Information: • I ;
1?.c.14.`WATER'LONESI:- t< I` -.. . .. .
Well tm tor Name FROM TO DESCRIPTION
ft ft. I 1
42z- .
NC Well Contractor Certification Number
E 1q;QUlER,CASINO:.(for,multi'cs"sed;w"el i)A1tTsTNER'(ifnp lic ilhlait 4 4;..U.fib%
Morgan Well &Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft ft. 61/8 m sdr21 pvc
Company Name • x.
.16..INNER.CASILIG'OR:TQBA�ICr(ge`ot eermal:close31oop) 't _.
2.Well Construction Permit#: � � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.107&,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft ft in.
w:17 SCREEN; := hls:<` '=;w=- _. _ :..: -
„
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IX Agricultural ,.( JMunicipal/Public ft. ft in.
X Geothermal(Heating/Cooling Supply) •! iResidential Water Supply(single) ,ft. ft in.
IiIndustrial/Commercial . DResidential Water Supply(shared) ,,18.,GHOUT'-• ,._ :-•-... -_-• -_. _ _ •
1 !I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
XI Monitoring )Recovery • ft. ft
Injection Well:
ft. ft.
*Aquifer Recharge DGroundwater Remediation
ti19 SAND/GRAVEL:PACK(ifapplicable)s*;L tr'' c'v.%... iz's"k?n=+. ' _
*Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL' EMPLACEMENT METHOD
"'Aquifer Test ®IStormwater Drainage ft ft.
d Experimental Technology Dom,Subsidence Control ft. ft. •
*Geothermal(Closed Loop) DTracer 20;D]2IINGTOG(attaehaddih_oral:sheetsifvecessary)t:,'`; "_`""_"'` _'
%Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
� 6 ft /6 ft. keddii4.4.Date Well(s)Completed:-(-I rat I 9-3 Well ID# 117 ft z-i* ft. '6j'6 coil'G l ri-
Sa. ell Location: 5 ft. (7 ft.
Q!k� *
J ft ft. 'blue
i, -_J 'rY,In t be
Facility/Owner Name Facility ID#(if applicable) ft ft f�JC e��w,`M-
Ling 4,-66raturckeet eicvla,h6L-AL ft. ft.
` ical Address,City,and Zip ft, ft, I
• T`- rg i a• 0i 3 F:21. MaRYS :...7.,Z . :g.. : ,. ....i,....,:. .::Y .t st., ; e•: is 023
•County arce entificationNo.(PIN) 9 i
DWCyli--OG t nz
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiend,one lat/long is sufficient) � 22.C cation:�� '
e 5,6`i N 1 1( w
6.Is(are)the well(s)t0Permanent or �ITemporary Sigoa f , •
ed Well Contractor a
By s mg th rm,I hereby certify that thelwell(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:' SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: DOD (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 2Q100') 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,iRaleigh,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
(Le.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) 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: 'fgtd completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016