GW1--01574_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
c1 w n gontractor Information: j
�0� �I/1 . ..
, , •. .
illiSVATEB;17,OPIES:?. $3 a �'v'�; 4f: ilr fe ;ii"c '.z'r_z.,raoi ''F,°i Y F--'3
tN--«-•MM'' FROM TO DESCRIPTION
Well Co3 Name
t�-5 ft12.11 ft.
ft. ft rrbl
NC Well Contractor Certification Number oY '' "y
.i�.1_ o t:We01400gif nl eia-1 ►�'e lij OIMINIIt(ifisp Lcanlalar .:3u#".-,: r -
Morgan WeII.&Pump, INC .FROM TO DIAMETER THICKNESS MATERIAL
1 ft II 4 ft 61/8 rn sd21 pvc
- Company Name r �,., Y » .u„
/� (y •
619 LINER(3ASING tlitilti:KO thetma'Itakal rLMi r vu � - �
2.Well Construction Permit#: d.(0�53- . .' 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: =I7.31SG'KE NIIC .rz r - •'s :3c�w 3'x3 —�rS .'trf:. '.A.,,;..3.:rr 4_�
PP Y FROM TO • DIAMETER SLOT SIZE •THICKNESS MATERIAL
U]Agricultural • DMunicipal/Public ft. -ft. in.
U Geothermal(Heating/Cooling Supply) 1111Residential Water Supply(single) ft ft• in. •
MI Industrial/Commercial . EliResidential Water Supply(shared) wretrosKQ:ul:,j s_"3 _am �"' vriv iw'i'im 3m••
Irrigation - FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' bentonite poured
*Monitoring . fRecovery - ft ft
Injection Well: •
ft. ft.
*Aquifer Recharge • fJ Groundwater Remediation N Y = r� �_.., r p
• 19 SAfi1M TGR ,Q:ELIE CIE a60i41i'eJ .,- r as ., ,
*Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
U Aquifer Test 13Stormwater Drainage ft. ft. .• .
j.Experimental Technology. Subsidence Control
ft. ft.
U Geothermal(Closed Loop) QlTracer ZU?D]till3`Ik G..L•'Q (atl'i"chiaddrHo re eeirrIMec_esang T :'�1
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) ,
■ Geothermal(Heating/Cooling"Return) MC/flier(explain under#21 Remarks) O ft •,5 ft reo A`
`s ft. i�{J ft. p. ]w.� _ r:.�•
4.Date Well(s)Completed: Well ID# J a 6. .._.�,,, '
5a.Well Location: .
3t5 ft 55 f. iw r rab t. t Pa i. �.t
�' MAN 0 b 20L4
Facility/Owner Name Facility ID#(if applicable) it. . ft. ��L J ^
ft ft. t{Nvu1,« ace cf 4� ��i
(A q el �'w VA ga1i.s�►;ri me_Zgt DANCAiBOG
al Address,City,and Zip
icp
W� M`dRKS' W-7—'4" =4—W1irr fr- � m
•-vLRE cF..
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.CQYfi'fication:
Signs o rtified Well Contractor Date
6.Is(are)the wellXIs) permanent or ©J Temporary i
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 X®INo 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 lids 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:' ''��//�� •
SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: D-65 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following: ,
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 • (in.) 244b.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.) f
' Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 .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: , 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 Revised 2-22-2016