GW1--06377_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
(Pi\' --5re, s
:,F4 WATER,7ANES q?,, ,_., .... -.: -,_ , ! ;
FROM TO DESCRIPTION
Well Contractor ame , ft. ft. 1 -
c656. 4• ft. ft i
r ,
NC Well Contractor Certification Number r15=0ualhleci1SIN,G:(foi multi.eased v¢e71s)ORTIIVER,(iEap'licable)_ ,.,„>-:?'
Morgan Well &Pump, INC ' FROM TO DIAMETER' THICKNESS MATERIAL
1 ft J j ft 6 1/8 sd21 pvc
Company Name `7 ^^
P Y - ,�`7 7�(�� z-16 31!iNER:C'' IPIG ORcLUBING(geo.;liermaI�clo-s`ed:loop7�'s4^ ,.
2.Well Construction Permit#: `J 7 , ) 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: R CREKO •c�_'ali ,.: ..: • ">
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DI Agricultural )Municipal/Public ft. ft. in.
)Geothermal(Heating/Cooling Supply). �I Residential Water Supply(single) ft ft in. '
Industrial/Commercial , DResidential Water Supply(shared) !1KGROUT'msmu?.,- .- :- ., ," - - , _ :'..
IPIrrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well: ft ft
jiiAquiferRechazge Groundwater Remediation i19 SAND/GRA;VF TACIi"ff;.appliF.alilej r
•iAqmfer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
1;Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft. '
%i Geothermal(Closed Loop) 'OTracer 20;37RIIiLIPTGI O.G(ntfscl ad8i6o'n"al:shee f ne`ceasary) _-
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rocktype grain size etc.)
— ft {, ft. �tfG�Jl�� /ir
4.Date Well(s)Completed: ` Well ID# (2 6 ft ��q ft. Sati C�
5a.Well Location: $ft 716t.
.h J ft ( I bte, • 0)�G4/1�
((��ft ft 'el
loct4 MotSlr lad .
Facility/Owner Name Facility)D#(if applicable) ft. ft.
1 `f ) 8' flf14✓4 4J ft. ft I t.. '�"k Mr �(E F '':
ft ft
Physical Address,City,and Zip 9
County Parcel Identification No.(PIN) ti ,. ••!i,
liTiOTA%t r.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r't /'�' R'-1.`
(if well field,one lat//longin is sufficient) 22..Certification: • -
X-5 p l6"/I . N Q- 003/f 7(J W 41111101111f J ..- --- )t,
C-73
6.Is(are)the well(s)�ix'Permanent or ®I Temporary Signature o erhfied Well Con i or 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: j1 Yes or XI 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 421 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.65 (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@100) construction to the following:
10.Static water level below top of casing: / "an (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 '
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotar
y above,also submit one copy of this farm within 30 days of completion of well
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) 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 I copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 6/is V' .., completion of well construction to th county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016