GW1--06347_Well Construction - GW1_20230927

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.We Contractor Information: .31:41 00y1,
FROM TO DESCRIPTION
WellC tra tor Name ft ft
1.
32z-A. ft ft
NC Well Contractor Certification Number i;',. >(
,15:OUTER,gAS1NG•foi;*,mnlfai.saiThdells)OIt'iI0F.R�(if "liczble)zx�=;;•;',G,y'at F'v
Morgan Well&Pump, INC FROM T , DIAMETER I I THICKNESS MATERIAL
1 ft 5Qit) it 61/8 m' sdr21 pvc
Company Name . ��11L 4
1� V�+11 7;Y6)l!INTER.GASII�IG;OR>FU1f11IGr(geo'thesloe`e`d"-sop):�:��.;;�:�.�:;r=f:is :� r>::
2.Well Construction Permit#:� ✓` -" , FROM TO DIAMETER I 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. +
K17.SOREENr,,,.I,' 't=€+'.%.`c-*.i.r".s;i•`. e rim Y •.r:'Y,t* •=h4" V..'f<'K<
Water Supply Well: • FROM TO DIAMETER SLOT SIZE z, THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
)Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft ft in. '
Industrial/Commercial Residential Water Supply(shared) •t 83,GR0UTff.' r.F:i" :%:';4:;'-s"..:''"::.::`'`:'s'':., "'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft bentonite poured
i Monitoring DJ Recovery • ft ft.
Injection Well: ft ft
Aquifer Recharge �J Groundwater Remediation
fIR'SAD/G.RA'VELI'A�C%(if zpplicable7s
Aquifer Storage and Recovery �J Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStormwater Drainage it ft
Li Experimental Technology �]Subsidence Control ft. it
Geothermal(Closed Loop) Tracer (:2lI ): GIO.O4a'ttsMicldiWilal:saeW.;f nece"s-SFO):'•'..Ir.Z:-1t ilt:r�Ki; 2 4_'__-
_ FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks)
•
b ft - 4C f. 6Y ke*. &A-'
4.Date Well(s)Completed:CA�)1),X Well ID# l0 ft 3b ft. \ r 1(16R' k- .5a.Well Location: 36 it LIAO ft k Cyb +
r`�1 . ft. ft
Facilitt'yy/��•OJwnerr Name1 l Facility)D#(if applicable) 7p� ft ft t
`U S -a•i `k1 Y e ....-J�� iJci z,ca .5 ft ft r":= m Y_.+ µ ) S.1--
-F_)
ft ft
• Ph sical Address,City,and Zip :,t s:r z.• ;.a
Parcel Identification No.(PIN) 5 l ."
County 7,-:•,a• -•.,1.1:-:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G: a 5'1L7
(if well field,one lat/long is sufficient) 22.C ' cation:
%,d.11Aa N 10.10)-5° W 6.Is(are)the well(s)kkPermanent or Temporary Sinf ifiedWell Contractor D/31
0
By s mg t rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or lallo 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:' 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:"'[Z� (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp e a@200'and 2@100) construction to the following:
10.Static water level below top of casing: v (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 (tl-) 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
13a.Yield(gpm) 1 0 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: DID OZ 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