GW1--06362_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only:
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1.We Contractor Information: ,
-1711 Adtit;4':�:4V4�It:zo1!tEs;,��At-�r._� t'"i
WellC tta tor Name FROM O DESCRIPTION I I
tic ft it ft. 0...yP f
3.4 . lA bbft 4 -ftI .
NC Well Contractor Certification Number r fSN; .D.TER?Ci*r$ISia'atlrmniti: dwells)OR'T 7ER(if:ali'licable)lte.L.3;4i.r;i W.1
Morgan Well &Pump, INC FROM TO DIAMETER t THICKNESS MATERIAL
1 it 'tg" ft 61/8 m'+ sdr21 pvc
Company Name t 43,
mP Y �hl�MOO-.
�l /�l/�I� 7�'163)3Yl�IER.C�SII�iG;07tt'kU13IN�{geo`th`eimal'closed�7uop):�:;E;•.;,.,"z��'�";"f.. �.r..�,
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
•
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
°.17.SORF+EN1;iY.vrt' 't ;azf—'c*.•t.1-_'a•: r.,,_.;:.I'...'v :4,:`_`�ra•a ^v`. f':c-_'i:.'�.:-.f.' •
Water Supply Well: FROM TO DIAMETER SLOT SUEs THICKNESS . MATERIAL
Agricultural Dj Municipal/Public ft • ft in. .
0 Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in. ' •
IImidusiria1/Commercia1 Residential Water Supply(shared) tj8 GROIIrtS_^wi`r... . � `:•:. .f' -.-'` ':`"' `j``:•:=:;ti . 5 •
,_!I Irrigation FROM TO J :` MATERIAL MLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring )Recovery ft. ft
Injection Well: it ft.
(Aquifer Recharge )Groundwater Remediation ?19 SAND/ P. ( -livable s
PP �...,...: .• "
'3Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
I Aquifer Test ®II Stormwater Drainage It ft
Experimental Technology ®II Subsidence Control it ft.
I''Geothermal(Closed Loop) Tracer ft2DD1 Ii7GZO;G;(ettfelfadditi"ovalslie"et3'ir.iaces`easy):ii'r :3."r?'<•iT^4;-X.: ::s>
Geothermal(Heating/Cooling Return) p�POther(explain under#21 Remarks) FROM TO DESCRIPTI (color,hardness,sai]/roektype grain size,etc.)
/lift 'b ft. Vyj,k �i'4.Date Well(s)Completed irl\ Well DV I, ft '? ft.,b'Tt�� el' tr�
ll Location: o ft ft ADYzsuh
N\` K/ot) LIS ft. 96 .ft ni
F ility/Owner Name Facility ID#(if applicable) [10 ft ft VS;` O' icJ
1-ArM vrbwV- t4\\66vg41 Wr3ter
Ac 2Za3I te. V
Je.i
ft. ;
• apical Address,City,iandZam
era '21:`B' .�1:'<'.-...a ... "� "- :`f:r!g_qSc:ra:sr,. . `:;_.&..v ";h's
County . Parcel Identification No.(PIN) ^r f 1 11"'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p c) I 2 n�3
(if well field,one lat/long is sufficient) C
22.C • cation: i J ,,��i�s i
10I' n"m';fir+..
6.Is(are)the well(s)*Permanent or Temporary Sigma f • ed Well Contractor Da
J.
By s e mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 10Yes or 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. 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:i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4AC) (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 2 a@100') construction to the following: 1
10.Static water level below top of casing: SS (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. 1 1
(ie.auger,rotary,cable,direct push,etc.) • j
Division of Water Resources, t derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce er,Ttaleigh,NC 27699-1636
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13a.Yield(gpm) 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: 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