GW1--05714_Well Construction - GW1_20230905

`I Print Form;' ;`
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
,1.Wey.Contractor Information: 1 '
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:14TERZONE3;1 a:W: _s. >: s. r:
ft. R 6 ft. t�'`a> `
WellC Ira tor Name tZttWA
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34 Ln 27-16c ft. ft. 1
NC Well Contractor Certification Number ":15 OUTER.CASING(foi:mniti-c`sse`dwelle)ORIINER(tfap licfible)' :;F:0:>:t :,
Morgan Well &Pump, INC FROM yTO . DIAMETER THICKNESS MATERIAL
1 ft. 1 /1 .1 ft. 61/8 :in' sd21 pvc
Company Name � � ��VGGa���IN
d6INNERCASING"OATiIBING'(geotlie=mal'closed=loop): ': :- 'tsx:•i:_` fi,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it. ft. ;in. .
3.Well Use(check well use): ft ft in
Water Supply Well: ;;17:'SCREEN .- vtiT .�s r':'.' ,,f° =, _., ,. : <, �.- ..: .:..,._-1 .
_
FROM TO v DIAMETER ~SLOT STLJS THICKNESS MATERIAL
Ig Agricultural )Municipal/Public ft. ft. in.
•Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) • ft. ft. in. '
•Industrial/Commercial E3Residential Water Supply(shared) `318:'GROUT . .. li:r +._•= s.� ::.r 1 tip .,,.'r".
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite I poured
JOiMonitoring }Recovery ft ft
Injection Well:
ft. ft.
Aquifer Recharge LIGroundwater Remediation •
:19:SAND/GRAVEL PAt (if applibsble')i .�:.__::•' •sr ' S ,'_,v•
Aquifer Storage and Recovery ag i Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft ft.
Experimental Technology Di
Subsidence Control it ft.
Geothermal(Closed Loop) Tracer 30.DRIL. aLLOCIftttichtadditioniIiliats3fneciiiii y)ea e,:{4,1•D i! :M:'j
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DES TIo (cotor, artiness,soil/rock type,grain size,etc.)
ft. \6 ft.
4.Date Well(s)Completed Well ID# 1 c..1 ft W:2 ft il:.z.y t.6 L�'>I
Well LLocatiQn:A' ft 56 ft ft k �J`a r.
Facility//�OwnerNanme Facility lD#(if applicable) nn�1 ft. ft -' r' i''¶ ,l,..I.,1
fT�LW v6,i L b`C.�L�.�..,.,5� ft. ft �-L.L.i t� +...
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sical Address,City,an Zip I� r� f t ft. 'p SEP V t1 �02,3
L"�.1c \ l '. cBlv o 21 1VIAR .zx «6,,:—i. t. .4..--:a._ ..- a+b ri`. :::r. ; t:a�_,
IflivlrF,2iir:� �rx.s�.sw,�(:I:
County . Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
.- (ifweell field,one lat/long is sufficient) t 22.C�' cation:! _
•
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6.Is(are)the well(s)+IPermanent or Temporary Signs f ied Well Contractor at
By s ng th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or ®tNo 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:' r, SUBMITTAL INSTRUCTION_ S
9.Total well depth below land surface: 1 K,L5 (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 2@100') construction to the following:
10.Static water level below top of casing: t) (ft.) Division of Water Resource,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 Iniection Wells: In addition Ito: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) )L) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit ode copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: I i el completion of well construction to the county health department of the county
t where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016