GW1--01576_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
.-Cl W 11f'ontractor Information:
� 44NVA:T'ERIZoi!IEs-fOg''gMi,a n= lr:-6W� `%'f -``a_ o".t�1"'�:rx IFAT,?
FROM TO DESCRIPTION
Well Con Name n ft �� ft.
aa- A 9p ' •
ft. ft
NC Well Contractor Certification Number ,''l6P-0•II;TER A:SIIV. `i mnligrai"`e3felli EZINE (if ap faiie)'i gr..a`M- -
Morgan WeII.&Pump, INC PROM o DIAMETER THICKNESS MATERIAL
1 ft ft 61 f8 in' sd21 pvc
- Company Name - .-Y
permits ZII� kty, ) ==16..11N1Ett. ASiNGOR.TUBIKaadg liTai'"Is_"caosed lavP t' 1 -•t
2.Well Construction Permit#: mom. TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction ermits i.e. ou State,Variance,etc. .ft. ft. . in. .
3.Well Use(check well use): ft. ft. in. '
Water Supply Well: - • 231
0 ' 055 �
Mo s •THICKNESS MATERIAL
jj Agricultural • 0Municipal/Public ft. •ft. in.
13Geothermal(Heating/Cooling Supply) ::;!Residential Water Supply(single) ft ft in. •
DIndustrial/Commercial _ DResidential Water Supply(shared) rk18.FiG-ko:•••• " € x - f e= ` 4
rit Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring r3Recovery ft. ft. .
Injection Well: ft ft.
•
A uifer Recharge - fl Groundwater Remediation L
4 g YP`ACK(iL'appficslil'e), _.:' wg=.ga '^V
QlAquifer Storage and Recovdry 0 Salinity Barrier PROM TO MATERIAL. EMPLACEMENT METHOD
EI Aquifer Test ©IStormwater Drainage ft. ft.
Experimental Technology. Subsidence Control ft. ft.
Geothermal(Closed Loop) !Tracer h29 tDRI1 v11IG'.xo•G(a't"fa'°ch`tiiftdrtionsl mtteetr 'necessaryy M- 1:Wr •tls'
FROM TO DESCRIPTION(color,hardness soillrock type,gratin size,etc.) ,
Ell Geothermal(Heating/Cooling Return) fJ Other(explain under#21 Remarks) Cs ft tr) ft r r
4.Date Well(s)Completed:2121 j UUl' Weil ID# 15 ft. 5 ft. - ; {. \ ,•tb."
5a.Well Location: 5 ft '15• ft br0uil^ yracki MAR 0 S 2024
n 5 ft. /�/tiG ft. 4 ti 0` °�rnh'els ' l �1 r`�J t t 1
Facility/Owner Name `�,/'� I��(�� Facility ID#(if applicable) ft. ft. J tyq,�r,e, ien arcs: r U&l
•
;$k) p - t ' �'�ILJf101 r�A✓ ty ft. ft. 4}VtiCu6:3C;i
P ical Address,City nd Zip ft. ft
s,,,
62.D- Via
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.C cation: c�
35. lfJ4� N t \�� w '��� t� �iO
6.Is(are)the well(s)Jx Permanent or offemporary Signs o ttified Well Contractor Dat
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 EiNo with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lmown 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: •
• SUBMIT TAL INSTRUCTIONS -
9.Total well depth below land surface: (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: 1.-K (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 - Om) 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,directpusb,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) ri -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: �b , completion of well construction to the county health department of the county
V where constructed.
Form OW-1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016