GW1--06459_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only: '
1.We Contractor Information:
FROM TO DESCRIPTION I
Well C tra tor Name ••�� t M
‘a-Sit. 1d'D `0�e
t'- . ft. i 7 ft L O Yam',
NC Well Contractor Certification Number r-m O ' i'
,cSS,OIITER'Ge1SFNG(fb"s.;multi=:cv. wells)ORTs'TLVERFCtBaplic'able)i�cj;r�:s�Yt�,�,'.
Morgan Well&Pump, INC FROM To, DIAMETER i ! TSICItNEss 1 MATERIAL
1 ft 6 ft 61/8 m' ' sd21 pm
Company Name• - - =s '•: y
�J�}(� ."•y1G .GASI11iG;O��:UI3INGr'`(ge`o't}i'eim'al"closed=lbop•�;�. �����:',:."..:::-;
2.Well Construction Permit#: I Ot/ ,/C O 0 FROM TO DIAMETER ', THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ounty,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): nnff tz wi ft in.
`,17.kftE•Ngl.l'a�-•_' 4+-.-.S::cL:•isv':'n:,fiiiS"..ei.-4n=`v.1-91.: :a `•.Atilili :L.-''a,l.,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS' vA MATERIAL T
)J Agricultural DMunicipal/Public ft ft in. , .
0 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
DIndustrial/Commercial . �IResidential Water Supply(shared) tjg?:GROVE 5w
lIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite ' poured
Monitoring )Recovery ft. ft.
Injection Well: it ft. 1 .
*Aquifer Recharge D Groundwater Remediation .
i<19 SAND/GRA1?L PAC&(if appTciable)s:`. - - '
•Aquifer Storage and Recovery Ell Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
MI Aquifer Test ®IStormwaterDrainage it ft
I Experimental Technology nSubsidence Control ft ft. •
*Geothermal(Closed Loop) ID Tracer 2DTDRII;'GIItIG iGG(attacl additioiielsIleet3zt".heces`sary) -k, R '-iz:ZI -- `.=' :
0Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Lardness sai/rock type,grain size,etc.)
i ` S' ft rein, �t r
4.Date Well(s)Complete I \\l)-"S Well ID#
6 ft.5 ft /� f >RjLt�I1,i �lV'e
Sa.Well Loca ion: �d ft `mod' ra� I, c,
1 I\/1 Y- �' V1 �fj ft ‘Ssft- G1tY f1 G(�G�.,��C
Facil`ity/Owwnerr Name Facility ID#(if applicable)
),- a ,
,, `LV` 4114fegdrAJAWIR.611 t,�Ls\G ft ft
- Physical Address,City,and Zip lig •
ft ft .^"4 . L rl it i'"r J
22) O r 4'
County l/„yh(`) Parcel Identification No.(PIN) O C T 0 S 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: inkJ.t�:_,i- er:�.^.G'y • l;r.,
(if well field,one lat/long is sufficient) (� 22.C• .• cation:e �.r�Q 3�•Q ,
76 N ,, 1�%61 W - e( t'� (aS
6.Is(are)the well(s)kPermanent or ®ITemporary Signaii4,/,f ed Well Contractor Date t
By s_ rug 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 15A 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#2I 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:' SUBMITTAL INSTRUCTIONS
Q
9.Total well depth below land surface: US (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-S3g 200'and 2Q100) construction to the following:
10.Static water level below top of casing: 40
0 (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. ! '
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent fr,Raleigh,NC 27699-1636
13a.Yield(gpm) aCD Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
6the addresses) above, also submit one(copy of this form within 30 days of
13b.Disinfection type: granulated chlorine X Amount: , completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j: Revised 2-22-2016