GW1--05710_Well Construction - GW1_20230905

l Pririt Form '
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
'5e, 1-14:.WATERZONES,:;s.."%i.">y'::i'<'L''sr F-;. _. ,. - Ri.,..,,.;;f,:,--. i.. ; z ti`. .
Well Contractor Name FROM TO DESCRIPTION
��"" 4 ft. ft. H
NC Well Contractor Certification Number ,15:.OUTEICCASING'(for ailinkifsed wells)'OREINER.(fiji llcable)'^-:'t i"i:„+2. i•;
Morgan Well &Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL
1 ft. 1 ft. 61/8 I hi* sd21 pvc
Company Name L/
s
� 7 �3 A.6 NNER CASING:OR�TDBING;(geotHeimel do`ned=lo'op)„ % ; ti i'0�: ""'._:`.
2.Well Construction Permit#: (/I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
`17::SCREEN.., ..:..ii I., .. -T. .-..:an*..r 7 M.,. j k..,
Water Supply Well: ti
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural )Municipal/Public ft. ft. in.
•Geothermal(Heating/Cooling Supply) Ai Residential Water Supply(single) ft ft. in. .
M+Industrial/Commercial E3Residential Water Supply(shared) 1.8:GROUT.„ `i.cit .,h ,r, -,'.t,. r. , ?. ._ .,
'I Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite poured
•1Monitoring D Recovery ft. ft
Injection Well:
ft. ft.
*i Aquifer Recharge 0 Groundwater Remediation
ca.1 T.SAND/GRAVEL:PACK-(if applicable) .. , „
*Aquifer Storage and Recovery J Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD f
*Aquifer Test 10Stormwater Drainage ft ft. i
•Experimental Technology ®I Subsidence Control ft. ft.
,*'Geothermal(Closed Loop) EllTracer i'20:.DRIL-LING_:OG(attlicliadditionalstieets f:neeeasary),a ta,.; ..>:.-_ •-
j Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION alo ardneas,soi/rsck type grain size eta)
0 ft /' Q ft
• „ ( J/I L
4.Date Well(s)Completed: /`1''13 Well ID# �j�j ft. •S b ft. 1.0c'1W(!j a.,�'4
5a.Well Location: + � ft 1 �I O ft. l/�g r-'I t\ , ,„r/i1
-670,y". 4 t7+1;, I� f- 16s-ft !g /Wej 0vCb,, ,,`L�1 n ,
Facility/Owner Name /p�� / Facility ID#(if applicable) ft L •J ft �/
// 1ei,t, p ft. ft
IC1
Physical Address,City,and.Zip ft. ft \ L.1:i j f d''�
,�-(/ 1 ti 21 REMARRS31.L'su. . ,,:_,- ,....5,..�_..J-' -- ...,,'.• ,an ,�1: .Z;i ,:
County Parcel Identification No.(PIN) EN 0 2��3 _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lllrti.rT4';�n �'^^
(if well field,eld,one lat/long is sufficient) /l 7 7 22.Certificatio • D r+)j oG
3S.S 07 NIP.'7 `D'1,J W
6.Is(are)the well(s) Permanent or Temporary Signature Ce e ell Con etor Date
J
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: )Yes or X3 No with 1SA 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:' COS-
SUBMITTAL INSTRUCTIONS
I9.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: .0 (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 (ill.) 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 27699-1636
13a.Yield(gpm) 3a _ Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
�� the address(es) above, also submit and 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016