GW1--05713_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.We Contractor Information: i
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ii4.WATEIV-ZONES_-i-V ' _ r
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FROM TO DESCRIPTION(
Well C trm tor Name ft ft
42z—A.
ft ft
NC Well Contractor Certification Number _ .. j'y
0.-Q1./TE1ZCASING.(facmultisased veils):.ORJANRI(if:'ip hcalile);ems . 3;�y'
Morgan Well&Pump, INC FROM DIAMETERI : THICKNESS MATERIAL
1 ft eio ft 61/8 Im sd21 pvc
Company Name, O 5 ®. .116?;IIVNER.CASII!ILLL G OR T[JBING eili 'ii)W a "eotlietmahclosed=l'o`o
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.
Water Supply :17;:5--CREENI.-!..1"4'i•:.:'._..:-:.:._+.�.. _...„ ..;._.-......_._:,.......�'��'": .:,: �... ::..
PP y FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
Agricultural ( j Municipal/Public ft ft in. J
Geothermal(Heating/Cooling Supply) ", 'Residential Water Supply(single)
Industrial/Commercial
ft in.�IResidential Water Supply(shared) ;.
asIGROUS.;i121. .. it r' •: ir'i �':i^'^. -.``•.
Irrigation •FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 it PO ft bentontte poured
Monitoring Recovery ft. ft.
Injection Well:
. ft. ft
Aquifer Recharge El Groundwater Remediation '
<19 SAND/GRAVEI.PAC&(i1:applieable)K°=° ; 41.a.1- ', s
(Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
EllAquifer Test ®IJ Stormwater Drainage ft • ft. I' •
i Experimental Technology Ell SubsidenceControl ft. ft •
DGeothermal(Closed Loop) in Tracer $:2o.-IiRIl I1�TGL0'G(a'flociiad'ditionaI:slieetsifbe"cea"sa`ryj' 'sx,;�•' _.`<'«'.t4=
ril Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTIo {color hardness,soil/rock type grain size etc.)
4.Date Well(s)Completed:V i.k if) ) Well ID# ek.�ftrft.\ 1ot)S \ ` .
5 . ell Location: `�Sftft• yb to W
lac, 71
1./I
J111 Si eft t Able `trelkniltf�
Facility/Owner Nam A
�L�Facili #(if applic ble) ft ft
aq 6 • p�. V. 41 �+ i' ... � �l ft ft t-.
P e 1AJd(dre�ssss,,/Ciitty,andZi ��a� ft ft i-� * t/ _..a
� l �1ry'1). C ° SA w I 6 '21 RF.MARTCC_ Y'_ _q': r .:: :-. .. k_`..f �,,..,, `_,`::-r'. ,,„, ;,,.F�
County . Parcel Identification No.(PII� 5 E P ' 8 02
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i ce'rime.`-"' •e--.-_
(if well field,one lat/longAis sufficient) �(� 22.C ' cation: I D* 1 t)Ga
3 N IJ�J n W 2 I C!
6.Is(are)the well(s) Permanent or Temporary Signs f ed Well Contractor Date
By s 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: 5 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2Qa 100') construction to the following:
• 10.Static water level below top of casing: S S (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1\..J Method of test: air pressure 24c.For Water Supply&Injection Well's: In addition to sending the form to
the address(es) above, also submit onel copy of this form within 30 days of
granulated chlorine .6?-1-2..) com completion of well construction to the coup health de artment of the county
13b.Disinfection type: Amount: P I county P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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