GW1--06461_Well Construction - GW1_20231002

•
WELL CONSTRUCTION RECORD (GW-1) • For Internal Use Only:
1.We Contractor Information:
FROM TO DESCRIPTION
Well C tra tor Name
lc5 ft ( f. ? hr+
427-716C. ft ft ��
NC Well Contractor Certification Number .r..s �ii pie•k. -
'15.:QIISER`G`ASING(£oi;multi:casedtivells)OR�I.�TEit,(if:p lica`b7ene:6•:.G'lz.`?i H
Morgan Well&Pump, INC FROM TO DIAMETER i I THICKNESS MATERIAL
1 ft 11C) -t 61/8 ill' ' sdr21 pvc
Company Name. �J
w��� �':16;pYLVER,C9$IIdG:OR;PUliINGr eoth'eimalclosed�loo' �;��•_;;:'� ;`>
2.Well Construction Permit#: �1 W� FROM , TO DIAMETER : THICKNESS MATERIAL
List all applicable well construction permits(i.e.UT County,Slate,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN<>:< _t+ .. -` t'l* .Ica ,i sTA:°t:i:�`fu:'. .::.t r:;.. h1:34: �;i32:'r
FROM TO L DIAMETER SLOT SIZE THICKNESS+ MATERIAL
II]Agricultural fMunicipal/Public ft. ft in. • .
I Geothermal(Heating/Cooling Supply) ;Residential Water Supply(single) - g. ft ' in. -
j*iIndustrial/Commercial ©IJ Residential Water Supply(shared) t1SGROUrii:;• ,ci "-..• m.,.f.' '.'' .•• : a?,i
_;I Irrigation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft PO ft bentonite • poured
X1Monitoring )l Recovery ft ft
Injection Well: ft ft.
Aquifer Recharge loGroundwater Remediation
i419 SAND/GRAVEIi.EAC&(11=.appltcableri : 1 '
I
AquiferStorageandRecovery �SalnityBarrier FROM ' TO MATERIAL • EMPLACE .MENT METHOD
Aquifer Test ®IStormwater Drainage ft ftExperimental Technology Subsidence Control ft ft •
Geothermal(Closed Loop) Tracer 'e.tio p GliO;G(attic additioualsheetsif necessary):i,u r.5== �!Geothermal(Heating/Cooling Return) nJ Other(explain under#21 Remarks) FROM zz�o,, DESCI22IP oN(color,hardness,soii/rocktype Praia size etc.)
a ft .7,0 yt tV`�
4.Date Well(s)Completed: l`.22/t%3 Well ID# 2'4) ft 4() D. I _-(,`Y', dt1(A'
5a.Well Location: , 4 ft 96 ft.6 bfQlAV1' roe1...
Vate a e ms 'plea' '1 b ft 2.c iftt
ly all,1-�
ft
Facility// wner Name Facility ID#(if applicable)
7facfiNac. 3��' tr.r a acW i c- it ct
ft. ft ;'
ft ft. I v-- 7:: ',, f ' )
- Physical Address,City,and Zip FM1- ti g :j `��/ ;_t ,
O\5-,qar� 34 '1Y21 RFM.AR7CC;?.;t'._... ..:,.'`s.• . ?'0�:"'t ik:sr_.:;�_'. : vz.,:1;.'i�'%:a
��
County Parcel Identification No.(PIN) Q VrJ fT0 7023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;.•�1 r
(if well field,one lat/longis sufficient) ` "'- D
d, 22.,P.M., Info rr"...Da*:L:Jan Lam:
I C� ( /2 .J7N W) W �, ,3
6.Is(are)the well(s), .Permanent or El Temporary Signae f ed Well Contractor ; Da
By ste„ 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 igNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
• If this is a repair,full out brown 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: CJ� (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(3100) construction to the following:
I
10.Static water level below top
of casing: Lk C:3 (ft) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In additionf toj 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 Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
13a.Yield(gpm) Method of test:
the address(es) above, also submit one 'copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: S 07 completion of well construction to the`county health department of the county
where constructed. Ik
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016