GW1--01573_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
sI W lLgontractorInformation: i
V () i�1:1>WATEIt)ZUP.IES.`ti-- 3,U-SWIr•sg H.-z a t"�tt �s'S�i
..'.7i"o`S? �i13�£-'x bis %1`.s—,,:-.f -`,Y`.:kL_s'�=�oFai'�:c3..'%�z3...o.
FROM TO DESCRIPTION
Well Con Name
3 -- A eesit.ft 16,6 ft. .
NC Well Contractor Certification Number v r. sv " n;
a iMbiFEIMMING+(fain nl cs.+ed'weOKa ORMNFR,(itirilcib'le)-MM OM:M • •-
Morgan Well.&Pump, INC FROM T DIAMETER THICKNESS MATERIAL
1 ft ft 61/8 'm. sdr21 pvc
Company Name h !16; tILVER..GAS •GOILTUBPN MWDIAl,c a"s`ed'-loo`p�n�r4 , -t '"-•4tE
2.Well Construction Permit#: SqA`''� 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 Su 1 Well: 114. S kgri irg..TMS -_'^ •r �'-'E -,- ;:- -
PP Y FROM TO • DIAMETER SLOT SIZE •THICKNESS MATERIAL
•Agricultural • fMunicipal/Public ft. .ft. in.
•Geothermal(Heating/Cooling Supply) paResidential Water Supply(single) ft ft in.
*Industrial/Commercial . ®Residential Water Supply(shared) FA8-t-G-Q`U, ; ru,� _- ?`if g
'Irrigation FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • o ft. 20 ft bentonite poured
- Monitoring Recovery ft. ft.
Injection Well: •
ft. ft.
*Aquifer Recharge • 0 Groundwater Remediation __ <. �. - - a � ,. �,.
• 14_S-91�1 rda EI%11x tIgi[ap ilicntil'e)tii a L�- `_--=.a l
*Aquifer Storage and Recovery InSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test ©IStormwater Drainage ft. ft. .
•Experimental Technology, Subsidence Control ft. ft.
•Geothermal(Closed Loop) r Q rlTracer I,63:iItT Ti1£7kial:c (a'lfiac iTaillon>z e� tree :�•n`ec_eaTac '.v, �,. --
FROM TO DESCRIPTION(color,hardness,saillrack type,grain size,etc.) ,
Geothermal(Heating/Cooling Return) n1 Other(explain under#21 Remarks) ft. ft
0 1 O - 6v4., .
4.Date Well(s)Cpmpleted:DlOt0-4Well ID# • `b it ag5 ft rtivy Y-6 v V. t ,':'C i' ,1� (-e: ��
ID ft '2 5 ft „ L.,,w...i. l Lam. `
5a.' 'ell Location: J c ,4 ,
.•Cn (8k -35 ft. LVA5 ft. Srtei qr er.; .MAR Q b ZO24
Facility/OwnerN Facility ID#(if applicable)
•
�/ ft. ft. ��� � � x-
9 J l i�tYA11`K.r R6 �� NM' �D'i) ft. ft. t1 'r,,,v...
(3iP.k.u5';Ey
ft. ft.
Ph Address,City,and Zip
fo_rs
iLZDRES. �%'�.�•tiM:yN:sk�''.`.-��.�-•_rv ;�`'�=
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22(7,.
cation:
„5553 N a5'3 W ' .
6.Is(are)the well(s) X.,Permanent or �IJ Temporary
Signs o rtified Well Contractor Date
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 IDNo with 15A NCAC 02C.0100 or 15ANCAC 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.
drilled:' •
��j SUBMITTAL INSTRUCTIONS -
"
9.Total well depth below land surface: d (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 a 200'and 2@100' construction to the following:
10.Static water level below top of casing: A-.5 (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:
(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 the copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 11 p-y 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