GW1--06346_Well Construction - GW1_20230927

MF I t Form x •�•
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
V°1\ 'Tod( i�V._ ia:wATERzoNEs < .:.:: t >... ... . ._ _., .- .,.....
• Well Contractor N�me FROM TO - DESCRIPTION
(155 6 . ft ft I
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NC Well Contractor Certification Number f4.5i.0UPER.CASING.(formulti=casedwella)`ORLINER'(ifap`lieable) ;;:;5.```t;:'r'+C" 'i'
Morgan Well&Pump, INC FROM TO DIAMETER ' .THICKNESS MATERIAL
1 ft ft 6 1/8 jin sd21 pvc
Company Name G spy ; .V
• - IN^('�iP i2,_ b it 11 '16:iINNER C' G:ORTUBIN (pe'o'tlier'mal'cibsed loop) , s
2.Well Construction Permit#: - J '1 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): it it 111'
.•17t,SCREEN giit ,.`>.1 y `r. t,.Egf:il rn...�I KO.... . _'
Water Supply Well: FROM TO DIAMETER ;SLOT SIZE THICKNESS MATERIAL 'I Agricultural )MunicipaYPublic ft ft. in.
MI Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
• MI Industrial/Commercial OResidential Water Supply(shared) h"1s GROUT _x r:' '.,tS.; ... ` :.4:,:s. '. . P:''
1 I Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite i poured
•!Monitoring ORecovery ft. ft. ;
Injection Well: ft ft
XI Aquifer Recharge DGroundwater Remediation
`7_;19:SAND/GRAVEL PACIK(if applicable)r`*.a{..,.r :. :,ve..1
iAquifer Storage and Recovery al Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 0 Stormwater Drainage ft. ft.
110 Experimental Technology Subsidence Control ft. ft
II Geothermal(Closed Loop) IDTracer `20 DRILLINGI;OG'(ett relf ddition`ai"sheet`a fi9`eceasaiy) %igz}=-%>'_s_eft; .:'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
V]Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) d ft �"�h it Woe)f1 t
4.Date Well(s)Completed: I Well ID# d !`'' Q'rt.
5a.Well Location:� 7 ft �0 ft IJJ/ e, j (), 2
r-i / ft ft
f.
Facility/Owner Name Facility ID#(if applicable) ft ft ,r.;t,_`' y/,L-f:l's: tlz_.
-26 i(/..ci aSCeoGv ed ft ft SEP d 7 2023
Physical Address,City,and Zip
l21 REMARKS. v=F»=_'c;:;A:.,L. :,a:. .4_,i:_ -ir f c.,- ;•'," :�[i.;,T ,',',2c
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County Parcel Identification No.(PIN) °t`'-" .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one l{at}long is sufficient) 22.Certification:
�.�U�Jc N /j0--7o761- W
6.Is(are)the well(s) IJX Permanent or Temporary
Signature of d elf Con ctor ,, Date
• 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: °Yes or Xi No with 15ANCAC 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. I'
23.Site diagram or additional welt 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
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9.Total well depth below land surface: � (t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-S@200'and 2@a 100') construction to the following:
10.Static water level below top of casing: L j V (ft) Division of Water Resources,Information Processing Unit,
1.
If water 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
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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSe ONLY: 1636 Mail Service C Tn t
Eer,Raleigh,NC 27699-1636
13a.Yield(gpm) ?... Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine / ,5 bz completion of well construction tot tide county health department of the county
13b.Disinfection type: Amount: O
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
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