GW1--07843_Well Construction - GW1_20231205

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
'ci W n Qontractor�Information: •
V („) fr4WATEMotiES: 'r `-"t ' 1I6- lladat iiMilM zcaPv".i 1r s:•;:-ew
OM O DESCRIPTION
Well Co Name i�V ft T1 l ft. `0 a� •
3 4 ft. ft V` ! '
NC Well Contractor Certification Number • aO.�DiTER,@95I1!l;G+{rmnlfigc*Wwella ORAILIDR;`(ifap licib"le)�..`j`a9M
Morgan Well.&Pump, INC .FROM TO DIAMETER t THICKNESS 1 MATERIAL
1 ft ft• 6 1/8 in. sd21
• Company Name , . ----.,..--...._w --tea lagali i zx c ' c..
3C jdAS GgR 1[lE�l!i(� eothe=msacoce�lg4
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.
ft ft. in.
IWell Use(check well use): ��r
,s17�$CFtEE�I'5�:�1s� 5 • �� ��,o�e.,.r
Water Supply Well: JZ
FROM TO • - DIAMETER 1 SLOTsN. •THICKNESS MATERIAL.
Agricultural DMunicipal/Public ft •ft. . in.
Geothermal(Heating/Cooling Supply) W1(Residential Water Supply(single) ft in.
J Industrial/Commercial �IResidential Water Supply(shared) >j--Sr-ea0_— ; gz.. .- mg; 4 -'-
•
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 20 ft• bentonite poured
•
Monitoring . fRecovery ft. ft
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Injection Well: •
- ft. ft.
_Aquifer Recharge - DGroundwater Remediation z� _.__ _ ......... .; ,. �.r- :. -
ri�
•
• ,��19�5`91'�TI1�Q1A�i�tYCB(ifiaPPLcatil'e):,����-:-a7c.`�..+ �. ..d..�r�i:�`{:,t
Aquifer Storage and Recovery DSalinityBarrieI FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IS t ormw ater
IStormwater Drainage ft. ft. •• •
Subsidence Control ft. ft
J Experimental Technology. � '
DTracer t } Grath..cli('addrbloas 4fieet%ifinecesan y' .' .
Geothermal(Closed Loop) r Fuom O'
,FROM TO DESCRIPTION(color,hardness,soillrocktype,main size,eta)
Geothermal(Heatin/Cooling Return) ll Other(explain under#21 Remarks) O ft 'TO ft (red,(IA.
. 2.� ft. 35 ft 6Y dirt
4.Date Well(s)Cpmpleted:11( (' SWell ID#
5a.Well Location: • 5b ft I yracgis 4-k:b,-.. - ft. s/�/�1ft b �w4%c Facility ID#(if applicable) ft. ft. ICJ
Facility/ rNam t pp ) .
. V1161 V t sir .2. ft ft _ _
ft. ft —..�rian; 1
Physical Address,City,and Zip I� g s fir r�
a-1rN 556 Z023
County, Parcel Identification No.(PIN) •
'' }�
lnforz-,�;i�;l i�r.^.•G:afG.T:fi�� VtQ2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: [3trrP ; t
(if well field,oneon lat/1long is sufficient) Q /�(� 22.C cation:
-S•.LO lc)-` ' N OCD ti Yd 6-L -- W l
Signs o rtified Well Contractor Date
6.Is(are)the well(s)0Permanent or C Temp orary
By ing s form,I hereby cerhfy that the well(s)was'(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo 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 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 alsoattachadditionalpagesifnecessary.
drilled:' •
•
����yy,,,,,,�� SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: c�i� (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@I00) construction to the following.
1
10.Static water level below top of casing: LAb (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 (Ina) 24b.For Injection Welts: 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.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
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13a.Yield(gpm) o .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 clays of
13b.Disinfection type: granulated chlorine Amount: •Dj1..,$Z completion of well construction to the county health department of the county
where constructed. I '
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016