GW1--01577_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
4 W ontractorInform,ation:
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i f4tWATE.WYA)NES; a`s -'�'.`.-, ' ?-ca t a 2 �r;�':ti2tr i:M e o4.3?s't'' off. 'r:
«--i�cGJJ FROM _ TO DESCRIPTION
Well Coon Name
3 1 -- �S ft. (•Zp ft. �1� r L. .
A6 ft. `ls ft. C!' ►J(yeriel
NC Well Contractor Certification Number ( ^" Y' ) ( p ) "
a'',�lOO.UR'ER CA$INGI formulliK e3„3".d11 ORMER-' i tcab'IaMISP . -
Morgan Well,&Pump, INC .FROM TO- _` DIAMETER THICKNESS MATERIAL
1 ft. "l f((, ft• 61I8 in sdr2l pvc
• Company Name .� ` _ ;7..,
p y I £3 Jo !1 ILI�IERdASINGORTUEIlLG`,(ReotheimalcTdse�loo Y ,,,-•v o
2.Well Construction Permit#: L 1 S 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: t-IVAS OitlIit > ' _--" �''' y� 119 z r It
PP Y FROM TO • • DIAMETER SLOT SIZE •THICKNESS MATERIAL
�J Agricultural • fMunicipal/Public ft. •ft. in.
)Geothermal(Heating/Cooling Supply) t''IResidential Water Supply(single) ft it in-
Industrial/Commercial Residential Water Supply(shared) . ri,. - c1L
;^„�,18'.�GR©Uil, fi sa ct.,s,-�i�
Irrigation FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
Monitoring . DRecovery ft. ft.
Injection Well: ft. ft.
DA4uiferRecharga fGroundwaterRemediation �Y�SL� (RGA�tilat1- a I ahle) .,Ia afar W.M45 ,
InAquifeI Storage and Recovery 0I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStormwater Drainage ft. ft. .. .
fExperimental Technology. ®I Subsidence Control ft ft.
Geothermal(Closed Loop) , QlTracer Pi20N3D121O131N .xr0:drat ch'tads%tionsle e'"(;Wecesaacyicy}' '`�,-.-._ " :- tkW
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) ,
n Geothermal(Heating/Cooling Return)l r1 Other(explain under#21 Remarks) ft. ft. �1%(/i� `
Tit
4.Date Well(s)Completed:� �a Well ID# t` it. 46 ft ` .,:G.�•kV-,--it 1, ' .,
1 �t/ d `�F�M.L �,� G
L h it
'1 5 ft byata. tl'Oc Lf
5a.Well Location: V 1,
\uoh ' ft. `1, ft. (� •
MNH 0 8 20/4
Facility/Owner Name FacilityID#(if applicable) bS ft. V� ft. ya.ir‘kit.Inforii-,.m!:Ti' A/Pp ) i � � �� �._.._,
�50 ��.."`'�`LI LA Ste" 'A ni(uo ft. ft. ..,,ra,•1,4'If;U'A3�.
ft. ft.
ical Address,City,and Zip J +/,, 1 1
agRF:NL`AI27CC'„ "- WV --iu"'L�:v�7-'scfi' rt'Wir " 4%'„� �.�3���a
County Parcel Identification No.(PIN) •5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.C cation:
.5k57€3 N iAt3O W 21. .)-y
6.Is(are)the well(s) Permanent or Temporary
Signs o riffled Well Contractor Date
XI
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: jYes or EtNo with 15A NCAC 02C.0100 or 1SANCAC 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:1 SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 4' (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']andme 2@100) construction to the following:
10.Static water level below top of casing: 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 " (ilL) 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
13a.Yield(gpm) 6 .Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
r - • the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: LP C2- 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