GW1--05742_Well Construction - GW1_20230905

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.We Contractor Information:
Well C tre tor Name FROM TO DESCRIPTION I
ft. ft [ 1
�4 Lf�.y[�''A it ft
•
NC Well Contractor Certification Number :r x• -.
;ar QIITER(st'S1NG'(iaii ula aaediv"ell's);ORI (i£ajip rObl rA?. ';:d its,;
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS 1 MATERIAL
1 it ft 61/8 m' sd21 pvc
Company Name,
3X; ,GA$Il\G:OItTlJ$ILYCy ea ermal;close-ng•`' 0-lir;r'•P;:'i:.",;:-•:`-
2.Well Construction Permit#0 - (,0)-3 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. i.
Water Supply Well: r17.SOREE 2t!.-__:ti? :Iz?'.<C•zi a;;?ti?,:<;.r= fi:v 'w` ._`".-. '=`-yg.�i-.:a =1;�
FROM TO. DIAMETER SLOT SUE THICKNESS . MATERIAL
DJ Agricultural JJ Municipal/Public ft ft, in.
DGeothermal(Heating/Cooling Supply) ',L_jiResidential Water Supply(single) - ft ft in,
DIndustrialJCommercial Residential Water Supply(shared) iT$tGROUTi!:sue,. .. _. •j'..;;iF '`` .-t•`.=k_:`rY• :+Y, - . .
'�lrrrigation 'FROM TO ...-F�'MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
®IMonitoring DIJ Recovery ft. ft.
Injection Well: .
�,�, ft ft.
0
*Aquifer Recharge Groundwater Remediation •• ,
09YSAD1DfGRAV?EJI.P ;CS trfaglirfablejr3'
*Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL - EMPLACEMENT METHOD _
•iAquifer Test ®1StormwaterDrainage ft ft.
t Experimental Technology IniSubsidence Control ft. ft .
NI Geothermal(Closed Loop) ©ITracer r:2D D? Si7GZO;G(attachi-dditioparsheet.riflrecessa'r"y):•;r n,_�� .:ter*':_
®Geothermal(Heating/Cooling Return) Other(explain'under#21 Remarks) FROM TO • `DESCRIPTION(color,hardness,soil/rock type grain size,etc.) +
() p l?1 17 100-'-' Well ID# '3J ` , 1( .
ft ft4.Date Wells Com Ieted:. ft � ft bY��u� 1�! ,
5a. ell Location: -5 ITi -
ft � '�'ftsl�v� irtc,i�,
t4
•
n� As it. 1 ft b��t t. f�YC1�k�ia s--�� +'
Fac' ty/Owner Name Facility ID#(if applicable) ft ft `�d.!tT, �l" '�
V�I- \CAV 1 CISY�' NC•' ft ft SEP a :,, ?C��
Ph al Address,City,and Zip l� �(�I-y ft ft t J
� L 915..` .t.AR`KS--�. ..�.:%,.s-. -'s--4 -:t ',,... ,llf' wt r. ae4;i1441�-et'.'w17•!Mis:"Vi
County v�� *)-3 --22,-3(7)-1,
aelTdentificationo1N) e 0 3
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well fieeld_one lat/long is sufficient) a 22.C • cation:
:2 ,,,,2 . -TS . '''
6.Is(are)the well(s)>�Permanent or Temporary Signs f ed Well Contractor D
By s mg th rm,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or ®No • with 15ANCAC 02C.0100 or ISANCAC 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 I
9.Total well depth below land surface:ADS- (ft) 24a.For AU Wells: Submit this formlwithin 30 days of completion of well
For multiple wells list all depths if dierent(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,!Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rota ' . above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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) air pressure 24c.For Water Supply&Infection Wells: In addition to sendingthe form to
�� Method of test:
the address(es) above, also submit one '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.
i
Form GW-1 • North Carolina Department of Environmental Quality-Division of Water Resources 1 , Revised 2-22-2016