GW1--05777_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: (+ j
et 1.4 tI
la 1,d WATER ZONES o- ;=lS G;, .. r..e2 i,'
Well Contrac rName FROM TO DESCRIPTION
9c46 ft. ft. f
ft. ft
NC Well Contractor Certification Number. .';15.:OUTER CASING foc"inniti%ciiied`welle'ORIONER. a" licible--,:*;•:,;".::•:
Morgan Well &Pump, INC • FROM TO DIAMETER I THICKNESS MATERIAL
1 ft p^ ft' 61/8 I. l'' sd21 pvc
Company Name (spit,
• /�� 16:�11•WERCAS ORTOBING`(Redtliaimsl'dostdloopr:: ":=_.- ,:.-,..-
2.Well Construction Permit#: )'t , 7Q Z. O�/V 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: 17 SCREEN,_r,:::"� :3 r:... f, ;_ . :- ,.. ' ; '`-
FROM TO DIAMETER SLOT SILL THICKNESS MATERIAL
t Agricultural DMunicipal/Public ft. ft in.
:•Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
*Industrial/Commercial Residential Water Supply(shared) z 18:GROIIT-10 " . .. •":',"':',11. _. r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
MI Monitoring DRecovery ft. ft
Injection Well:
ft. ft
•iAquifer Recharge )Groundwater Remediation .
19iSAND/GRAVELPACK'(ifapplirable)'., `< ; =; ';'i.< :_`!='_::-r .:,-''- _._
•iAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL . EMPLACEMENT METHOD
MI Aquifer Test DStormwater Drainage ft. ft.
•Experimental Technology 0Subsidence Control ft. ft.
•!Geothermal(Closed Loop) ®II Tracer 12ll;DRIISdNG LOGatticli a30itioiial ilfeets3f'tieceelai ry)C3 h=:k• ..
•Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM O DESCRIPTION(color,hardness sail/rock type Brain size etc.)
G ft ft -t
4.Date Well(s)Completed: ii�0—_7,F7 Well ID# ck ft (no ft. 9 /N LOB /C
5a.Well Location: • ��t0 ft. I. f .. 014
'_ I l4 4;7 e
ft.
Facility/Owner Name Facility 1D#(if applicable) ft ft
J ? Lc �4, 1 LA ft. ft. 1 ['`
Physical Address,City,and Zip ft ft. li 1 C (_,E S\J��"p
/_•Iln_/j" f21''REMARKsij°: `F,V, sue._;; .,;a.4,,,'.:r:. . lit...:a'.8.. -.?. %.,„�,.,. .....
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County Parcel Identification No.(PIN) SEP J 5 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In`crr,.:'C i; ..,s4yo„:32 t)II
(if well field,one le/long is sufficient) 22.Cer" aWQ/e0G
35-[1/1 7'/ N lo-7 753 W I e' 1-2
3
6.Is(are)the well(s) Permanent or Temporary Signatur erti Well Contractor Date
JJX
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
• 7.Is this a repair to an existing well: DYes or EliNo 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:
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
r
9.Total well depth below land surface: ( (05 (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@200 and 2Qa 100') construction to the following: i
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
•
11.Borehole diameter: 6 (hi.) 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.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
air pressure 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
13a.Yield(gpm) � Method of test:
the address(es) above, also submit ohe 1 copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: CO i'S r 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 I Revised 2-22-2016