GW1--01558_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: •
l W Ils'ontractorInformation:
4 (� f'1'4'� :.A•1< .amoPtEo. '��':m` .ter s 'r..mg?�-""'_"'5 ':�x *�"I i'g-s r4 '
FROM TO DESCRIPTION
Well Co Name I ft �� ft. r i1
it. 1 ft �'i .
NC Well Contractor Certification Number 7" . "' �`.__ ... -'" .
:�I�'OU;t'�R;G+�95TNGY�:{r`.:multi.ca,e°d•�wella�OR�Z•"-71VER�if�a'�licb'le'_ �.. y,
Morgan Well.&Pump, INC .FROM TO DIAMETER l THICKNESS I MATERIAL.
• 1 it• r„T ft 61/6 m• sd21 pvc _
• Company Name" „..,. _ , ._.._ ...- - .-7" 3s a .
�.-�� _,.,7�6?,�rivn�R�C�r.ASIPIGQR1U�kiI.�C� thezmril(`c5osedlodP�; .;
2.Well Construction Permit#: 3 F�J 143 FROM- TO DIAMETER THICKNESS MATERIAL..
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): - ft ft. in. '
Water Supply Well:
M7 SCR PI & •� - s•
FROM TO DIAMETER SLOT SIZE •THICKNESS MATERIAL
Agricultural )Municipal/Public ft. .ft. in. .
Geothermal(Heating/Cooling Supply) % 'Residential Water Supply(single) ft ft. in. •
1IIndustriai/Commercial DResidential Water Supply(shared) g wou f; . rz-..- - ' =• • � .--- -
Irrigation '
FROM TO MATERIAL KAIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft• 20 ft bentonite poured
IM� onitoring . EiRecovery .. ft ft •
Injection Well: ft. ft.
EIAquiferRecharge - E1 GroundwaterRemediation w —. st
14 SI'1—1WACI alil cntile).Ms. :? 'rv,+ " . 'at
©I Aquifer Storage and Recovery 0 Salinity Barrier _FROM TO MATERIAL ' ' EMPLACEMENT METHOD
QII Aquifer Test ©IStormwater Drainage ft. ft.
Experimental Technology. ®I Subsidence Control . ft. ft.
Geothermal(Closed Loop) QII Tracer 2:03 Ti'Iki[.;>Q: a'.t ict$aharttioels'.: eces»y "`
FROM TO DESCRIPTION(calor,hardness,soillrocktype,grata size,etc.)
Geothermal(Heating/Cooling Return) 01 Other(explain under#21 Remarks) it ft K:, ;
I�� L� r�� a� . I:,T. , e
4.Date Well(s)Completed: l 1'A Well ID# . Ld ft. .-S ft bj/b1A1M:Ali • i . ,,�E.t , Li
5a.Well Location: 3s ft "t> ft b� y' k- ft/li\K 0 S )024
Al.-1°- -----ec'acility/os.
j l'� ft y5ft t ,,'t, % t ft. ft. Wtrt.t.}O•Oaiie;1�!'^ = ;g7 UFO
•• Facility ID#(if applicable) (}rl`-!a J,
ft. ft.
. C Lis u C
Ph icalAddress,City,and Zip ���7g�T eio••��-i ^� ft. ft.
County (JW Parcel IdentificationNo.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation: •
�51-SN 40a N l c0 W la�� r
6.Is(are)the well(s)4 �Permanent or IITemporary
Signs o rtifiedWellContractorate
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 EliNo 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 farm. 23.Site diagram or additional well details:
• 8.For Geaprobe/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:1 SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 clays 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: l V (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 • (n•) 24b.For Injection Wells: In addition Ito 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) ) 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: completion of well construction to the county health department of the county
where constructed.
FormGW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016