GW1--03936_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
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1. Contractor formation: . •
Q ':14 WA1$RZONES:$0:'. 7..t '•.i.'. `: i'Sri y ..,:ti:;'F ;.•'>S,:,
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Well Con torName FROM TO DESCRIPTION •
ok k 1 lb ft- )ZZ ft. et yr PI
NC Well Contractor Certification Number No I ft. '3 M b ft 1 S1tirS
15.:01T1:ERCASING:(f ci..mliltiC' divans)ORLIN=(tFa'lleible) ::::,' ":!:,;;;1;...;::
Morgan Well&Pump, INC • FROM ///TO� DIAMETER THICKNESS MATERIAL •
a ft. 4 ft. •61/8 in' sdr-21 PVC
Compaby Name
I�x�� �16.'IIVNEIt! - ' ING.OR;'lTl$1NG;(geottiecmalclosed-lodp):::;`:..i;:;,::::'.:::.k:::,^;:.;:<":�r: •
2.Well Construction Permit#: 40 y FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
• 3.Well Use(check well use): ft. ft in.
'177SCREEN.' •::::Y::,:. :': .' %1.`:•".,..... ." <i`:". .`:::.t<: <;r." ,::...
Water Supply Well: FROM TO DIAMETER ` SLOT SIZE THICKNESS MATERIAL <
Agricultural QMunicipal/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) "Residential Water Supply(single) ft ft. in.
I Industrial/Commercial Residential Water Supply(shared) i 18:GROUT •::.-, ::;'., -; ..:•::-.:.:.::
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft* bentonie poured
Monitoring Recovery ft. ft
Injection Well:
2)Aquifer Recharge • ID Groundwater Remediation ft
19:SAND/GRAVEL PACK applicable).
0-, J Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
)j Aquifer Test DStormwater Stormwater Drainage ft ft.
0Experimental Technology EllSubsidence Control ft ft. •
Geothermal(Closed Loop) 0Tracer .:203)=LING:L0G(a"ftaeli"sddit onai'sfieets7faecessary)':::-':r::":::`.:r:: ";• ..''>'.
')Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktypq grain size etc.)
/2 'JtWellID# d4.Date Well(s)Completed:( 0 � 35 ,� )Y( K !c(M' IJ
S Well Location:.
a 3S it
3/5 f' tut tro-v i-�
Facility/0 Name Facility ID#(if applicable) f. f. `
.» ,rol_ r c� CZ ` L,
\Z..2:)Address,City,and Zip _ .JUL ? 24:. ..
t -Y� I�$ kO « .. . ...:,-.
County Parcel Identification No.(PIN) • It orR'�E.V•7,l 1^rr '''3:�i44
V'A'C,t 30,4-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•
(if well field,one lat/longo is sufficient) �j 22. e '•cation•7, )
35f-j kCD N 0�. 153 W V �8r
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6.Is(are)the well(s)FJPermanent or l)Temporary Si, e o rtified Well Contractor Dat
By signing form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: .•Yes or F.A. No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 derails or well
. construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dimmed. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3j 5 (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 e@200'and 2@100) construction to the following:
10.Static water level below top of casing: 4 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2'7699-1617
11.Borehole diameter: 6 1/8 (in.) 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) Method of test: air 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: !5M. completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016