GW1--07126_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
,1.We Contractor Information:
• tl4':R�A1R 1640NES A, .. *. _ .., -... . • '. .
FROM TO DESCRIPTION
Well C tra tor Name • 125 ft ` ft , M
-342z—A. . 3 ft 341 ft 2.060, 1
NC Well Contractor Certification Number - i_._ ..•.
�;1$.,QITTERCt1S11!IG"(for�mniti: .dwells):OI2�If�lER?Cifap 7icabl@)ice•_-.3::,4ac;?=M
Morgan Well&Pump, INC FROM TO DIAMETER I THICKNESS MATERIAL -
1 ft ll�+ D' 61/8 m' sd21 pvc
Company Name , �I GG N
V V' 1�1� 16..Y-N CASI& .QRTLBING(eotli'ermslclose ioop);j .::,= .«:,r _::,t
2.Well Construction Permit#: FROM TO DIAMErrae THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft us.
3.Well Use(check well use): ft ft M.
17.SCREENFn e;•:r ..".'?`,n''..Z. "-'-s"? '�_`..i.fi ,J'^t,•%'.:t4.1,, e t,:PZ:t r tic%:.`;
Water Supply Well: FROM TO - DIAMETER ^SLOT SIZE :•THICKNESS.,_•MATERIAL
)Agricultural DMunicipal/Public ft ft. in. .
D Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft. in,
• QIndustrial/Commercial Residential Water Supply(shared) g;:GROUTii"w" . ;-i 'r" - :,;;fF' - '''i m
FlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non--Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft ft
q_Aquifer Recharge Groundwater Remediation
6"19:SM D/(RAV P.AC-&(if appbcable7s
Aquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage it ft.
(J Experimental Technology ©II Subsidence Control ft U.Geothermal(Closed Loop) Tracer ::1120 D CI TGtO;G-(atta-Crad'di6onatsheetsirnecessary)'.'.:{^:;:O 2':i .�:::i 4': l `
•
Li Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
(g g/ g Other(explain under#21 Remarks) 6 ft It ft tfirt `r
4.Date Well(s)Completed:1bl2,la3 Well IN I ft 36 ft rtsoC 1.
5a.Well Location: 35 ft 4. ft. lfu Xi vik
(�-a ' • ft, ry ft
v ft ft.
Facility/Owner��CC Name Factlity1ID_#.(if applicable)aQ
‘e)C , �, '�.. tsbuiy N;c 51,4i ft. ft. .
• Physical Address,City,and Zip JJJ 7/� J ft ft -
320 � oil_ {r21 RkMAR'KC <• .:.me.µ., . .. _
County . Parcel Identification No.(PIN) ,k p " w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • N O V t/ 1 •1 n23
(if well field,one lat/long is sufficient) 22.C- .1, cation: L 1,
35. 74t3 N 10.46 43 •i;c ,,_-
W
-�1-• - .`s'•' ,/.-' hijLl a-
6.Is(are)the well(s)�1Permanent or Di Temporary Signa 'fified Well Contractor Date
By s o ing VIM on,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes 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 Geoprabe/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:* 40 at) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if derent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: kb (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: ,
(ie.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
13a.yield(gpm) 3 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: \,(a... completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016