GW1--06478_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information: I
FROM TO DESCRIPTION?
WellC tta tor Name 37).6 ft 'YID—.ft. Et) ,
342z-. ft ft \Q• I�OYY 1
NC Well Contractor Certification Number - • -^^� ti
r15 QDTER`•CASING(�y.mNti3casedtivells);UlT�fiVl�:fifap-hc`ab7ej :tc.•"iai�fr=t
Morgan Well&Pump, INC FROM I�TO� DIAMETER i TTHICKNESS MATERIAL _
1 ft {� ft' 61/8 in'I Isd21 pvc
Company Name . ' , � ';16 XL�YER. (G�fi. G:0$.L'U11INC`r(eo-tliecrosl.close' .nop)'`Sicc'=:..o_;^1 .—.:r
2.Well Construction Permit#: FROM _ TO DIAMETER I, THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft in:,'
3.Well Use(check well use): it ft in
Water Supply well: :17.S ..::3rt X 'YY 7'✓?�>�C'k� �i V-.;?.."a r3'-i:F3x ".:'.�'_i`•-'i-''a:��i";;--k:ds.•3 :'%f';�
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
Industrial/Commercial . E3 Re s i d enti al Water Supply(shared) tio,GROurre,FT l.:c.` .• r<:.''`'. I.`" :` ` - 41,: .
I hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 40 ft bentonite poured
Monitoring ©I)Recovery ft ft
Injection Well: ft ft
Aquifer Recharge DGroundwater Remediation
€i19:SMW/GRA'VEL`.PACK(if•.ap`plieabld)s:
Aquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL EMPLACFMENTMETHOD
Aquifer Test DStormwater Drainage ft ft
U Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) •
Tracer s20?D tIetwcioG(attsc1Iigditiopa1slie"etsri£.neeeasar"y):t '.z:: .ho.t.
Other(explain under#21 Remarks) FROM TO DESCRI tON(color,hardness,soil/rock type,grain size,etc.)
CI Geothermal(Heating/Cooling Return) (xp FRO(
it ft �p � ,
•
4.Date Well(s)Completed 1 51A3 Well ID# \0 ft 36 youh I ncjCt� AYk, .
Weeell Location: ,.1 3 S ft. ' ft Y,a,
`,\ bwkivn5 �� ft -,fP ft-b�1tJ ll". �C, k-
Facility/Owneme v Fac''ty ID#(if applicable) ..2: ft' c.7�"LO ft 1/4.a\t►t+"C/ � ti
1(rJ e t\\CONOkt ft ft O.
ft
• PhiicalAdress,City,.and Zip I �, .-i :t .- V
®.,,,,t v P21?`RYi.M:ARKC;-.ti•< �::.:>>.., : `- 'tY5S: t+i7,:'i:,._�:%';.`!`3..:....>. ,U
County . Parcel Identification No.(PIN) OCT 0 2023
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: trtL i, 7 --.-- ' '"'n r'n
(iffwell field,one lat/loonng is sufficient) ( 22.C ' cation: �j+,°01(-7,7_,.......„7 l' a' '12
0 tas
iir
6.Is(are)the well(s)+Permanent or *Temporary Signs f mi.":,ed Well Contractor Date
By s ing 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 15ANCAC 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#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
9.Total well depth below land surface: '( (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:
I.
10.Static water level below top of casing: (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 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
(i.e.auger,rotary,cable,direct push,etc.) M 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5L/ Method of test: air pressure 24c.For Water Supply&Injection Wells:f 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 t Amount: \c az, completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016