GW1--05773_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: V
1.We Contractor Information:
' `llli WATIR?ZOhlESc ,...;:;:ifs at<<" _ . :rv:x:x:. -,, Sa i......_..attri`., &. -
Well C tra tor Name FROM TO DESCRIPTION I
ft ft V
3422711k ft. ft 11
NC Well Contractor Certification Number
i15"r,QITTERCa1SI1VG(foraiulfi=caserL'ivell's):;QIt°I:1NER'(ifap lc'.ab7eM:';-i?z"ci, ?�:.
Morgan Well &Pump, INC FROM 0 DIAME1r,7t THICKNESS MATERIAL
1 ft /f it. 61/8 in' sd21 pvc
Company Name . ckvki,..,frn
\fi r l` � a61: RG:.v.`G;ORTIIBlliOCOotlieimal:clo•red-ile-fi . ...:z,_-.:,_};, f'_l,,:` .•
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 Well: i-.1.1 SCREENz.`t?_;i::: :C�'t:i•;;ci ems-. . . ..
. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
II Agricultural jMunicipaUPublic ft ft in. .
1 Geothermal(Heating/Cooling Supply) C_.',Residential Water Supply(single) ft. ft. in. •
"Industrial/Commercial EIResidential Water Supply(shared) _.,5•,_ _ _ _ , - _.
IIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
rfill Monitoring • 0Recovery- • ft ft
Injection Well:
. ft ft
**Aquifer Recharge Groundwater Remediation < r�
i:C19,SAND/GRA.VEIIPACK(f aPplicable)'s: c:'i: '. _ :;;'t`;,„:: <4.:4-:s4 'a``= ..•tii:
*i Aquifer Storage and Recovery D1SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test ©IStormwater Drainage ft ft -
•Experimental Technology ®!Subsidence Control ft. ft. '
Ni Geothermal(Closed Loop) • [*Tracer j O DRIFMIGZO:G'(attacli`additiuriiI:`slieet;=i£riece"asaiyjl`� 1„xOlr _,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(c lor,hardness,soiUrocktype grain size,etc.)
I*
'. ft ft. raw ,
4.Date Well(s)Completed: Well ID# Lam,' ft a- 1' A.n re t •
•
Well Looccatioons (3- . ft. blue_. 3y-e4.3A
` c_
..40,06
f
Fac�ili^tyy//OwwnerrName Facility ID#(if applicable)
9(-I t•Vcri'e.Vgli Nt-6.Pkce_c, -.0,,,k- r it ft ���'°� 1�/ a"'R
ft ft StN ti t'UZ.i
PJ�ysicalAddress,City,and Zip _.:...-.:.-...- ._, :_,,.- ...:::. J.;-.,`-.
l//� 521:�RF.MARTCC�4':�`5' �"u.:. ::-ti:'; �i:¢5-::'�•{'o':�`�'�?�+:r'.
jibams
iiY'' l 1 r I,.f
County . Parcel Identification No.(PIN) DtL'r`L:.t.i.e•rn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.C cation: •
N � - w .
6.Is(are)the well(s)r�Permanent or Temporary Si�a74- Y-__
: il,. f fled Well Contractor'7,__.„2 6 ate
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: )Yes or *No with 15A NCAC 02C.0100 or 15ANCAC 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: t 45 (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(a3100) construction to the following:
10.Static water level below top of casing: 0 (ft) Division of Water Resources,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 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:
(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
air pressure 24c.For Water Supply&Injection We➢s:l In addition to sending Yield(gpm) �� Method of test: � the form to
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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016