GW1--05774_Well Construction - GW1_20230905

ILTRISTIA
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.We Contractor Information:
t i
faleoR'ATERIZONE$1.WM1gMU.3:=i z'g.' -ei..';;O I`.`i::4 - 7:"
Well C tra tor Name FROM TODESCRIPTION
ft. ft.
-34 -A ft ft.
i
NC Well Contractor Certification Number
;*15.QUTER'GA`511VG`(foi:multi=cased.;wells).UR`IiI1VER(isp Iresb7ej�,� c�" ,���
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL
1 ft ft. 61/8 !m' sdr21 pvc
Company Name,
16 INNER -ASING1OR:TITOING(eothe iiiiircltainoop)M "::_:,..-`'
2.Well Construction Permit#: Jew --x �"C[ ., FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e County, tate,Variance,etc.) ft ft 'in.
•
3.Well Use(check well use): ft ft ,in.
Water Supply Well: • Y•17 SCREEN_ : :-:=_:A=v:r =t z'`'-d ��
=:y -s- _;n:. T.� . . .. -.
FROM TO DIAMETER SLOT SLTETTHICKNESS MATERIAL
''UJ Agricultural JjMunicipal/Public ft ft in.
•
%Geothermal(Heating/Cooling Supply) ;'jlResidential Water Supply(single) ft. ft ' in. , •
*Industrial/Commercial . f Residential Wait,"Supply(shared) r'
�18„GROUP'-.:- .:•-:' •.
!I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft .20 ft bentonite poured
*Monitoring .• Recovery ft. ft. 1 .
• Injection Well: '
it ft.
Aquifer Recharge Groundwater Remediation
397.SANDXGRA3'EIS •
PAGIC-(ifa`pplieable)< 'n:r' ix' ai' ' <±L=
Aquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL -L, EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage •ft ft
Experimental Technology DISubsidence Control ft. ft
Geothermal(Closed Loop) )Tracer • illtI IZI NCIDG_(attiaicrditiunalstieet rligEeasiicyj wr;_- • -- _-. "
FROM .DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) a�.. it 4,3ft.
4.Date Well(s)Completed:1 ), Well ID# tft it nrakstv-:-
5a.Well Location: ft. ft .
ft ft etiA f^
s sa tom.4i..!17 e•\/ A^�
c' ty/ wner Name Facility ID#(if applicable) ft ft
n
` • ciA 1 �- ft. ft. 3 E P 5 Z 0Z.i
hysicalAddress,City,and Zip ft. ft. ' Infora- .ucll Pr.^.;:*4 tb,:' 1Jn,'N' .
211-ItElYIARKs.". ;,.... i.,;_s, ti. : Qsproip,f_ ig, ,
Inirt
County . Parcel Identification No.(PIN) d ri \th V J e1 tCe Y 46 / . ./D
zkifaCt,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one.lat/long is sufficient) ! 22.C• +: cation:
Cai
' 3� '` ` N /lr� W• lCJ V6.Is(are)the well(s)�1Permanent or 01 TemporarySignaP.�',.'f ed Well Contractorj�aie
By s th'rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or I.No - 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: .
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: (ft.) 24a. For All Wells: Submit this form I
c 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: '--�J (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,lR i leigh,NC 27699-1617
11.BorehoIe 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: i •
(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 2 7 69 9-1 63 6
• 13a.Yield(gpm) 6 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition_Yd`sending the form to
the address(es) above, also submit one copy of this forini within 30 days of
granulated chlorine
13b.Disinfection type: Amount: 6 _ completion of well construction to the county health departaient of the county
where constructed. ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I, • Revised 2-22-2016