GW1--06460_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
`1.Well Contractor Information:
f
:;14.'RVNTZR•ZCtI`IESW-:�F.7L.at: .. l:.f`'. '
FROM TO DESCRIPTION I
WellC tra tor Name E
°srct2z-A. it �[!`7 ft
•
i
NC Well Contractor Certification Number
r15 tOI1TER:CASIlYG(focliiiNfi=•ased.wells)OR%)f;ILVER;C�tpp-livable)n:q:4,;%•t{.a
Morgan Well &Pump, INC FROM To DIAMETER ' I THICKNESS '�'�'A'
1 ft t ft 61/8 ll°' sd21 pvc
Company Name . - ,a:,,, f ;. - ''
\��`��� "•:;.FROM ] .0 tr .G;OR�UI3IP METE tl a mat HICKNESS s:.k r" _..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL•
4.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft L Ili.`N 17.,5CREEll:>'.:f[:'.:-4 -,"ItKL e'1-?..-L ry :•...•_-'..P::4LI.T>v v.�.- .;•.%�:'iw.. �LVi.; -
'i
Water SnppIy Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural L)J Municipa]/Public ft ft in, .
0 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft• in.
DIndustrial/Commercial . ®II Residential Water Supply(shared) •118I GRO17Ti' ( ,�. -`i:%'sSn.ra. '=:'` '~-t :.;a'.
litilnigation
FROM TO MATERIAL'' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
DI Monitoring )Recovery - ft. ft C
Injection Well: ft ft
. -Aquifer Recharge )Groundwater Remediation
19:SAND/GRA3lEL PACK(if appl eabIt)s5=.'
Aquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft ft
U Experimental Technology �ISubsidence Control ft ft.
Geothermal(Closed Loop) Tracer 081.:4 Z2II Il\TGS:O;G:(attic7r additionals7iee.a.r3 Mcessa`r'y):.k=.. ? yT ,�r- :z>.`.?g:
FROM TO DESCRIP ON(color,hardness,sei]/rocktype,i;rain size,etc.)
I=i Geothermal(HeatingfCooling Return) Other(explain under#21 Remarks) ft \� ft. re:A '�i
11 C ,1 fit. •
4.Date Well(s)Completed:�\5I Well ID# 1‘S f't `I-S ft•k>� se. 6,d`(!i .
5a.Well Location: 1_c"t s f•b`�w�'- c�
C _c�wo�'a4•-0J 0saV a !5 ft \bbisft Aram) 6 y�$t
Facih�tyljOwnjer N FaciliD#(if applicable) ft ft - TA r�r�
I,S fJo �+ l 4' 11►'Mb`��k/ ft ft rTa �;,.,+�1,.5:.� ^•t1t .e,t! .+')
- Physical Address,City,and Zip 225
Q a/ti�' ft f. r �0 9 0,
1 • +- •D Co 1 7DREze •RK.C,?.... •'..pie., .....,,-,:z T`:= .'1�: .6^:tsV E; :+'r._,w
�J Parcel Identification No.(PII� {f;`.L's''':"` '`�1 3rr'
County D:''J>:,O OG •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) (� 22.C • cation: Q
' 6,1-\o S'S N qd, l -- w a , I 1
6.Is(are)the well(s)�IPermanent or ['Temporary Signa f ._ 2.,t,/),_
ed Well Contractor I. Date
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: DYes or 4No 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.
I
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:' SUBMITTAL INSTRUCTIONS
h/� i
9.Total well depth below land surface: 1,v v (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eramp e-3(200'and 2Q100') construction to the following:
10.Static water level below top of casing: £p (f.) Division of Water Resources,,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,lRaleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rota"' . above,also submit one copy of this fo i within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,IRaleigh,NC 27699-1636
13a.Yield(gpm) 1.S 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: '""75 ISZ 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.