GW1--00889_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: -
si W ILOontractorInform1atiion:
.1�1 •
t f�4'.r'ATERa7Als.10.` ':'1' ! ` =: k«�' ?£`.•.r'� x•ELd-:"e?AI Fr•.~�
�-�K} FROM TO DESCRIPTION
Well Co Name l r PS ft '/C, ft. ' Q E�1.I •
H ft. (O 7S ft `` I .
J -- N w
NC Well Contractor Certification Number , , "" iii ' + . .
�IS�"O",II¢�:$bGa9SIL�(GYEformulh:csue;�".eliaj�ORl7FLF_Hit,(itiaP"Lcnblej'�'�.,'� ,.�,c
Morgan WeII,&Pump, INC .FROM ' TO . DIAMETER I , THICKNESS MATERIAL
1 ft i ft 61/8 in. sd1 pvc
• Company Name• Rfr6j1 EI160 1Vatr aWeraeel?i o.: a• a
2.Well Construction Permit#: rkkl\ VIE—23- 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 • • _ DIAMEMR. SLOT SIZE ;•THICRX SS MATERIAL
Agricultural Municipal Public ft :ft. - in. '
0 Geothermal,(Heating/Cooling Supply) 'IResidential Water Supply(single) ft.: ft. in. • .
DIndustrial/Commercial . E3Residential Water Supply(shared) ,m--5 ia 0.ma i Ira s
ri I Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite • poured
DMonitoring . • Recovery ft ft.
Injection Well: ft. •ft •
0 Aquifer Recharge - 0GroundwaterRemediation f 3.: ve
rs77: 7,• GCS;(r£gpp-7`ciiii14w..�,�:%e4.5-,z.. ,LS -...6s,Atag
Qlj Aquifer Storage and Recovery D Salinity Barrier • FROM TO MATERIAL • EMPLACEMENT METHOD
DAquifer Test ©IStormwaterDrainage. ft. ft.
)J Experimental Technology. ®I Subsidence Control ft. ft.
In Geothermal(Closed Loop) ©ITracer • 5 20..3DItIt,Ti'11+i :Q. atF=ct fis drtiiraA, tr•..:.eces>,axy
FROM TO DESCRIPTION(color,hardness,soll/rocktype,grain size,etc.)
ril Geothermal(Heating/Cooling Return) i1 Other(explain under#21 Remarks) O
ft 1.5 ft �, _ \h CkLVt
4.Date Well(s)Completed:I.1 Vo[DIA Well ID# • 1S it. 35 it. brot", rneK
5Ca.Well Location: . • 'j>S ft •aOS ft bt �r c-�
..X)Yt.l� • • ft. ft ` ;
Facility/Owner Name 1� Facility ID#(if applicable) ft. ft J t ,,. „Ti-;::
A f. e 1 ,rft. •ft.
• �(a '7 C�� c� -}I�+�+/����•{ JAG �. ft. ft • rya 5 ii24
Physical Address,City,and Zip
/4 .rtlozorr uS • • Infra ir,24. .a err. .✓;:-...)uki.1
County Parcel Identification No.(PIN) DIN'JBC- " •
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation:
1
6.Is(are)the well(s) Permanent or 0Temporary
Signs o riffled Well Contractor • Da
X�1
By ing s form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EllINTo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remark 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: Dt6 • (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.
1 •
10.Static water level below top of casing: 46 (ft.) Division of Water Resources;Information Processing Unit,
If water 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:
(Le..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) .Method of test: air pressure 24c.For Water Supply&Injection Wells:s: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 0 bZ 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 i Revised 2-22-2016