GW1--00860_Well Construction - GW1_20240205

' WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
Si W 1TS'ontra�ctt-or�I�nfformation: •
ti (�Ek . ,• R7ANES.^ i t: g1.a a 2, ��xza m rr Y
1Esc Si' .it ""�;�„sr;.�v":i.l' .. w '3
Well Con Name • FROM TO DESCRIPTION.
��� � 515it ,�-� ft � qP� .
it. ft. U
NC Well Contractor Certification Number a "" " .' "•"' `s" "` .
•',�.I��..,QIIII'm,�ASILrG7(ior-wul£iscsu""a`lr,.n��`e"Ilaj�ORTF1yDR'(z1�iP licab'le)�..`1a�`•.�'.` 't�"�a
Morgan WeII.&Pump, INC .FROM TO DIAMETER I THICKNESS MATERIAL
i ft So ft 61/8 sdr21 vc
Company Name r •,'. :(, " 'C`i1"" ._"geatlicm4,rcose a • y
`\`\ • .�.C:RAT.�R..�.ASI�I.,.. .:%i'I7,$I'1!Z�GI �]R4P);%� _..�.'.� ,-.a� •
2.Well Construction Permit#: 1���0- 6 FROM. TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) 'ft. ft. . in.
3:Well Use(check well use): • . ft. ft. in. ' .
Water Supply Well: FROM TO • -u bXAMETER SLOT STi.E •THICKNESS MATERIAL
•Agricultural . EiMunicipal/Public ft. .ft. in. .
Bj Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft - in,
*Industrial/Commercial• . Reaiden1ial Water Supply(shared) gr-GRtiujt, mumigsgm' x "
•
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft hentanite poured
*Monitoring )Recovery ft. ft.
Injection Well: ft. •ft •
*Aquifer Recharge .. - 0 Groundwater Remediation 1ien_i i4 . �. ' (10pp�-"til4iWi2, � � b : .
*Aquifer Storage and Recovery QlSalinityBarrier . FROM TO MATERIAL, , EMPLACEMENT METHOD
*Aquifer Test DiStormwater Drainage ft ft. ..
Ni Experimental Technology. DISubsidence Control . ft. ft.
•Geothermal(Closed Loop) ' QIJ Tracer '2g)'3DR'IIiT i ll): itict adarfionscLa>z t.i>neeesra'
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.) ,
• Geothermal(Heating/Cooling Return)
1 (eturn) a. ID#niOther(explain under#21 Remarks) d ft l ft rta dirk
4.Date Well(s)Completed: I I lCt . , Well 15 ft I ft 'braW h aIf-
5a.Well Location: it 4O f. �TD IYOLt.
FIA)t Lh f_) R We (� ft 6US ft. 8ry,, .4 ct.,j' .
Facilliitty/
O�wnerName Facility ID#(if
Aapplicable) it. ft. �'yl
l 1.V 't� �4/103(1..a +V C 2 aN • ft ft.
Physical Address,City,and Zip ft. ft ' f ': -'--•.
County 1Parcel Identification No.(PIN) L CU 0 . z�
20Z4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation: i0itr"°•E..iznP-"-- -g ,
3S,2_cx.)6 . N %.9,g(o3 W -� , D YC:i3OG a5
1
6.Is(are)the well(s)JPermanent or ®I Temporary
Sigoa o rtified Well Contractor Ddte
By ing form,I hereby certrfy that'the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: DYes or ICJ No 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 also attach additional pages if necessary.
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drilled:1 SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: �b5 (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.
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
.o'
11.Borehole diameter: 6 • ( i.) 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.e.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) 3C Method of test: air pressure 24c.For Water Supply&Injecti n Wells: In addition to sending the form to
C the address(es) above, also submit]one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: • J C)Z completion of well construction to'the county health department of the county
where constructed. •
Form GW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016