GW1--05724_Well Construction - GW1_20230905

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ! •
1.We Contractor Information: I ,
t
14uWAVAtZ0lsT.'$w'.�. :twd: 6'-.l:,. .: .
WellC Ira for Name FROM TO DESCRIPTION i
,34 ft ft ;
" ft ft
NC Well Contractor Certification Number ';`1`5'QU'I'ERCAV/Wilis.;mNtirc sed_`4'ells)<OIt%ON427(if.ap-lica,leiree:;tSSa•.,,:t.q,
Morgan Well&Pump, INC .FROM TO DIAMETER I THICKNESS MATERIAL
1 ft IC:, ft' 61/8 in, sd21 pvc
Company Name. r.
l) `�- t). °' 3)1')/aiERC9SI OOR,4UANG..;01 li'ernia'I: seauopl: �_W.X5?r':11r0.`
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.a UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in
Water Supply Well: 0..7.SCREEEN-gii;ft .yz:LL1;F �i.t-3t:u:. -.U.:`:f: t ':",`.;`:- 4•=f ;,t>r;ei•:'E- %.F:
FROM TO DIAMETER SLOT SIZE � THICKNESS'� MATERIAL+
II Agricultural DMunicipal/Public ft ft in. •
I Geothermal(Heating/Cooling Supply) [kit Residential Water Supply(single) ft. ft in.
"I Industrial/Commercial E)Residential Water Supply(shared) t1StGROU1i{'ys.�:: . j ;-.,a''.x "`';:..'`' :"t` -
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
IIMonitoring DI Recovery • ft ft. •
Injection Well:
. ft ft i
"'Aquifer Recharge 0 Groundwater Remediation _
ri19ESAND/GRAVFY{.P.ACS(if1ppli'cable s _ -
*Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
II Aquifer Test ®IStormwater Drainage ft ft.
I Experimental Technology ®Il Subsidence Control ft ft • '
"I Geothermal(Closed Loop) OTracer F;•2ll:rain I1!TGIO;G,(nits"l additioRaTshe`etlif,Siece"ssary):;+f _ '-3? -cl h4...•
L•Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEseRD TIo (color,hardness,soWrocktype grain size,etc.)
r�� U ft ft. 11 --
4.Date Well(s)Completed Well ID# l ft J ft b ra t JN l l-_ .
•
5a.Well Location: 45 ft 95' ft b;,6�>;,'' hest'
eAN a �r�� • (15 ft 47 t, it t e.k c60'-vrt`� .
Facility/Owner
NName,, ` Facility Io#(if applicable) ft �-t� ft. i ` 777
,,„t•+M!tt ^ R
Physical Address,City,an ip ft. ft. ! S F n a ,)D
);,�,_` 321aRFMi1RKQ=; .• . . . '... 5-y.5"t:-,s,, .::.. _ ..1 N.:,,+ :i_':s3-
County � E
Parcel Identification No.(PIN) inatriaraUcfi
r�+� ���
( DW I Q/ -ttr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y
(if well field,one lat/long1 is sufficient) �( • 7�r^ 22.C ' cation:
()y)- �ld ]t N UIbOV { W (.2 (,' g1
6.Is(are)the well(s)I�Permanent or Di Temporary Signs f • ed Well Contractor Date
By s rung th rum,I hereby certify that the well(s)was(were)constructed in accordance i
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or ISA 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: I
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:1 SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form I 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: ' (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition t 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,direst 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) (0 Method of test:_air pressure 24c.For Water Supply&Iniection 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: Y t I l 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