GW1--01559_Well Construction - GW1_20240308

• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 •
4 W IT�Eontractor Information:
•KO A:TERMOPIES. r' ; ;11R 3"-�`Krr.'Yri--.cam' ?mot .e.gi 3°`-_--5`0"[�_o":l t'--'S rF �?..-'.''.
FROM TO DESCRIPTION
Well Con Name D- ft 7 ft. 31 1-.., .
-5 4 z� a c
5 ft• �� ft ),=.
NC Well Contractor Certification Number • °CIS'SOD`tCERi�ASRNGy(for=multi else,aRaiINFIWs(>t ip licab'le)k ltiaage,-fi`-,sc, ' ••
Morgan Weil-&Pump, INC .FROM TO DIAMETER : THLCFSS MATERIAL
• 1 it 130 ft 61/8 m• sd21 pvc
Company Name �._ .
`� �`1CRsCv9SIPIGQA:T �eothemn4;".oeed�l'-.o_4A)i� �.:ti�s�sx
2.Well Construction Permit#: J rl a. 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. �y Q
Water Supply Well: zX7 Fl TO
pp Y FROM TO • • DIAMETER SLOT SIZE •THICKNESS MATERIAL
Dj Agricultural • 0Municipal/Public ft •ft. in •
-
In Geothermal(Heating/Cooling Supply)- tn'i Residential Water Supply(single) ft ft in, '
DIndustrial/Commercial DResidential Water Supply(shared) agra Qti..„..._, , n7a* z
riIlrrig,ation FROM TO MATERIAL EMPLACEMENT METHOD&AMODNr
Non-Water Supply Well: 0 ft 20 ft bentonite poured
DMonitoring DRecovery ft. ft •
Injection Well: � •
ft. ft •
Aquifer Recharge - !Jt Groundwater Remediation
DAquifer Storage and Recovery OSalinityBarrier FROM ? TO MATERIAL , EMPLAeEMENTMETHOD
Dl Aquifer Test ©IStormwater Drainage ft. ft. ..
•
Experimental Technology. QSubsidence Control ft ft.
r
0Geothermal(Closed Loop) ©ITracer D;Fp�22'IDTi1kY Q.Wat ic] adartionalrehe'etrneceetn ' - -
FROM TO DES N(color,hardness,soiUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) �I Other(explain under#21 Remarks) a ft. ,) ' ft y�1
4.Date Well(s)Completed:1,1311A Well lD# 6 ft (us ft- 4)rt �v r^; 0 ..
6 ft l p ft ajwt� "4 i e�. c..
5acVbth
ll Location: {�c v l�O ft C�ft. �Jlrotoh Paz k MAN 0 S 2C24
Facility/Owner NameFacility ID#(if applicable) ..1 ft. -/Cbt. b Lv,L eiY� v`�`e/
t�`S S jdKr A tKi7�� C�11 �7� L ft. va.+l.Jft tl liui it"i:akcT ior T.O n
ft, ft •
Physical Address,City,and Zip
Vim`- � �_�.. ''��W
LJ ems. C>> &D 3
Margn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
N
� l`ii�•(if well field,one lat/long is sufficient) py �j 22.C cation:
c J� . Id.J 0r
„.74............D ,
__p_IA__
6.Is(are)the well(s)0Permanent or DTemporary
Sigma o- rtified Well Contractor Dat
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 XlNo with ISA 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 an 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:' •
�• SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: -IC`l (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: 45 (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'. • On.) 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,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) (Q 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: I2 6 7.-- 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 1 Revised 2-22-2016