GW1--07654_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD (GW-1.1 For Infernal Use Only:
sy w Il.Qontractor Information:
'r.r.44W.t�:TE1LZ011ES. r":il rf'I?'7,1`'s'.��t - It `nira ei'dn�as�..i�izB.k.:
O FROM TO !ESCRIPTION •
Well Co Name I A 5 ftI VI, ft ��'y'�, •
3 ft. ft j
NC Well Contractor Certification Number '°`"'" •
'.v�I•�''�.a.,O,ZTtFER:�ikSING?(forFmulliscss`"eil,,°`gellaj�Ol;T?IlyBIt,(if?p licab�le)�`ja`h�'���;;
Morgan Well.&Pump; INC FROM TO DIAMETER ' THICKNESS MATERIAL •
1 ft. VC) it 61/8 I m' sd21 pvc
• Company Name INS.
��y> ammo, 1l�IGpRLW�f - ee etma"ic�oeed�loc �-�"''�'"'��a�
�- _ --3` E
2.Well Construction Permit#. FROM, TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 'ft. ft. . in.
it ft. in. .
IWell Use(check well use): ¢ s
Water Supply Well: FROM TO • • MIAMETER SLOT SuLb •THICKNESS MATERIAL
Agricultural f Municipal/Public ft. •ft. • in.
Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) z BrCs PUTe• - -` '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation '
Non-Water Supply Well: o ft 20 ft bentonite • poured
Monitoring DRecovery ft. ft .
Injection Well: •
ft. ft.
Aquifer Recharge - DJ Groundwater Remediation -- --
ay. 5TAI81 GIRIX EVit 1 '(i£app'liailiTe)sy=��Y -.2"WRO .�
Aquifer Storage and Recovery ©I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test ©IStormwater Drainage ft ft. .. .
Experimental Technology. DSubsidence Control . ft. ft. •
Geothermal(Closed Loop) •• DTracer 2u)i i ON .T;o:( '(a't i"_-cbta illifi i;phea(r necessaicy. 'r
Other(explain under#21 Remarks FROMh TO DESCRIPTION(calor,hardness,saD/rocktype,grain size,etc.) ,
Geothermal(Heating/Cooling Return) �J (xp ) V it ft d
4.Date Well(s)Completed: . Well 1D# • \c ft. 4S ft-Sr r .
P 111 23. �t
5a.Well'Location: J�p� ?5 it
1O-° fib , //l
• ocke b Yi" • . . �' e ft W65 ft ��,,_ r -l)�, •
Facility ID# a applicable) it. ft. �(}y1�/�T,�
Facility/Owner Name $' (ifPp ) -
ft. ft
(4 @(`Q� c v t i .Y.-Ne ft ft
Physical Address,City,an
\ L2EnrAuiFfi� �
t �m unty Parcel o (PIN) ' T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
t7
35(if well field,one latilong is sufficient)- �jr 22.C cation: DEC ! 202+3,59..3( • N(70 a ` let W �1 . :'7t1'-:lg ''''
Signs o rtified Well Contractor s 0,3 Date
6.Is(are)the well(s)�IX Permanent or ©ITemporary j
By ing form,I hereby certify that the well(s)was-(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No X� 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.
repair under#21 remarks section or on the back of ihisfarm. 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: 3O ' (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi„#erent(example-3C3a 200'and 2Q100') construction to the following: i,
10.Static water level below top of casing: 4S (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 (Di.) 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:
(Le.auger,rotary,cable,directpush,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 SuDDIV&Injection Wells: In addition to sending the form to
• the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine completion of well construction to the county health department of the county
13b.Disinfection type: Amount: • 2 aL where constructed.
i
Form GW-1 • North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016