GW1--05723_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.We Contractor Information:
1
Well C tor Name FROM TO DESCRIPTION I
�4 ft. ft I I
• • ft ft.
NC Well Contractor CettificationNumber •
f;'1t?i'QUTER;GiA$ILYG(foPimulh=rived;wells)<OR%IllitiW(if.appliWeWA? :s.',fa't.
Morgan Well&Pump, INC FROM TO DIAMETER ; THICKNESS ll MATERIAL
1 it. GS ft 61/6 m. sd21 pvc
Company Name, x. s .. zg:,;c;^':.:y
[�\ L7�6� :;•16, '�GASIL1tC�:OR7'L7BING�eotli'eitival'close�uop� ;:.�v;=z�.`.,.-. .,
2.Well Construction Permit#: Ob FROM TO DIAMETER ! THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft m'
3.Well Use(check well use): ft ft in.
Water Supply Well: '4.17:S EENr'<;r=_T ;4 =Ir= e:.'i•)r2::rEi..,,r3. F ;tv.`r.:9`...A.R-;z-:SL i::..`- . lr
FROM TO DIAMETER SLOT SIZ.lt �� T=CKNESS MATERIAL
Agricultural Dj Municipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) [f 3yResidential Water Supply(single) ft ft ' in
ril Industrial/Commercial ®I Residential Water Supply(shared) 481:GROUTb .y. .. _ " -.`%'-•' ' :T f .
I Irrigation FROM TO MATERIAL ' EMPLACEMENT OD 8c
�Non-Water Supply Well:
ft 20 ft bentonite 5
Monitoring DRecovery , ft. . ft. i
Injection Well:
• it ft
_Aquifer Recharge �GroundwaterRemediation
I Aquifer Storage and Recovery • DSnlinity Barrier Aquifer Test
t 19 S9ND/GRAB r;P.ACg(if appliiablejs=+ _'
FROM TO MATERIAL � EMPLACEMENT METHOD
®il Stommwater Drainage ft ft.
LI Experimental Technology Subsidence Control ft. it
Geothermal(Closed Loop) ®ITracer 20rD TGZO;G,(atpicl sdiutaha else'iii ggisar'y): ;^ '-z.; `#fte..•r'a'
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
Ei Geothermal(Heating/Cooling Return) rJ,Other(explain under#21 Remarks) it �- ft I�
•
4.Date Well(s)Completed: O �1 1X Well ID# •ft 1-7) ft' (IlN O r' c.
5a Well Location: 5s ft. ,co.6 ft � t
e_,6us c•e_ y _-t, ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. ' �L..6 V 9.,.
Va-4,«. w b s c. ft ft. i . S E P a 5 2023
. Physicaly Address,f City,y,and Zip ft ft. t 1 1
1 • 1LiLJ APSC nt'XRATAR7tC.-i;t., ._...s,..-.. _ :w�-{fil'H!ttiv it4,, F�t.��w;4.144�
f'�C
CJ`.t136
County . Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one lat/long is sufficient) 22.C • cation:
ii' A� a ,
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>>4 ��G N t1�r w
6.Is(are)the well(s);.,.Permanent or Temporary Sign f ed Well Contractor Da
By s_ ing th rm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or ligNo with 15A NCAC 02C.0100 or 1SA 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach,additional pages if necessary.
wed pp�� SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: \,VC) (f) '24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-@ 00'and 2®100) construction to the following: 1
10.Static water level below top of casing: C� (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 Iniection Wells: In addition to sending the form to the address in 24a
rotary . above,also submit one copy of this forth within 30 days of completion of well
12.Well construction method: construction to the following:
(ie,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) 46 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit onelcdpy 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016