GW1--06450_Well Construction - GW1_20231002

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.We Contractor Information:
FROM TO DESCRIPTION I
.Well C Its tor Name Zg5 ft Z`1�lo " 6-) 6
427s4\C. it ft �t
NC Well Contractor CertidcationNumber F" .. '" :r e _ _z. .." . ,h":` '.�-0'
i:TSODTER;CiI:SIl!iG(for;moth:cised.�'e11sjAR%I7iVER=(if.ap Lcib7e)�sa5:.a•:•.-,::ai:a,�::
Morgan Well&Pump, INC FROM TO DIAMETER I 1 THICKNESS MATERIAL
1 ft ft 61/8 -'I sd21 pvc
Company Name, :'T.r''-•'•. •f4`
3G .'•;161NLVEI�C `.OItGFUiiING�e`o'th'ermalclose""d�-uop)�'�i �, =.:;.•::.,• o-:>
2.Well Construction Permit#: cj FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.. C,County,State,Variance,etc) ft ft in.
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ft ft
3.Well Use(check well use):
r1.7,SOREEN.' ''SLIP;,:,:F,•V,S.:-',-t:<:.•.t_� 7 e,-yew°4 '?;:",.J-_... :w':ds •?�•YrI
Water Supply Well: FROM TO' DIAMETER SLOT SIZE T'(:THICKNESS MATERIAL
DAgricultural Dj Municipal/Pnblic ft ft in. .
0Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) fti ft. in,
Industrial/Commercial • . DResidential Water Supply(shared) � T,.65 '•'`: :181:GROU .:r: is:., :..'""`'`- �`;.r`:s::'3rt� •. . • '...
i Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring DI Recovery ft. ft
Injection Well: ft ft.
**Aquifer Recharge 0Groundwater Remediation •0.3:9::SAND/G txun..P.ACK(rf applscable)s;s ..- - •. . -
*Aquifer Storage and Recovery DIJ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test LI,Stormwater Drainage ft ft•
X Experimental Technology D Subsidence Control ft ft ' '
*Geothermal(Closed Loop) D1 Tracer a 20sD.FI IlYGIO;G:(attnc7iadditroal:sl eetszfhex"e`ssar'y)::;^w 5ii: r-`1,'zv a:
FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc.)
O Geothermal(Heating/Cooling Return) rOther(explain under#21 Remarks) it 1 Q ft.
t DES Allele
4.Date Well(s)Completed:CI \ 12S Well ID# ,D it 35 ft � vh ` .
5a.Well Location: • •a5 It 55 ft i YEN. b k-
naVvi 1 e urz 5‹ ft kAy
66 A .
Facility/Owner Name c Facility lD#me,applicable) ft ft
(\iSreyr:ASI V l.`,3 mV Is 1..9 ft ft. i , t_J' .� i. `y w ir"
yr
ft ft
' (Physical Address,City,and Zip (�j T ,. �]
f 16 (�n� Ask cArl s21 RY+'.MXRTCs: .... ._., :-.... ._?;'LXr.•',-. 'Zd"-� .tLf-' :,:., '�,
County _ • . Parcel Identification No.(PIN) '`' _. - I t r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C • cation:2
4 .9066. N fib, " W 1 2,Ss a-�
6.Is(are)the well(s)�1Permanent or E1 Temporary
Signa f • ed Well Contractor • Da
By s mg th rm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or *No with ISA NCAC 02C.0100 or ISA 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:t (' `-�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� ( ) 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:
�.•� I, •
10.Static water level below top of casing: V (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 (n•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this foimiwithin 30 days of completion of well
12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service R Cente%, I aleigh,NC 27699-1636
13a.Yield(gpm) SC 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 chlodne 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