GW1--03947_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
• 1`W_l].Contractor Information:
J -rrem '14tiWAtFikt ONFSf.: ::.:'i�.;t ¢"r[>i-'.v::'i.W:'"iw, . .. x'' ;1 .'S.1'•.''
We1lCont rName FROM TO DESCRIPTION
34-4 -A 245 ft D Z.45
. ft t� estjM
ft fr ft
NC Well Contractor Certification Number '
152:0113:ERXCASIN :(fdr.:irintti.44ed.Wells)'ORLISER(tfap IIeable) ,:•'..:::•:::;:i:;•••,
•Morgan Well &Pump, INC • • FROM TO DIAMETER THICKNESS MATERIAL •
0 ft. 4 s it '6 1/8 in' sdr-21 PVC
Company Name ���
16.fVNER(CASING OR ti[7BING;(geottie ctiial eloaed loop):: '.: .-1.:;:::::.;';'.:.:,t<'.:;:•;t.::i,:
2.Well Construction Permit#: LtOriFROM 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° i°'
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft. R in, .
•
Industrial/Commercial $Residential Water Supply(shared) IB:Y>RODT '...:. r...'``..' ".. :<
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured ,
Monitoring Et Recovery ft. ft. .
Injection Well:
ft
Aquifer Recharge [1 Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable) .;
Aquifer Storage and Recovery $Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft• ft
Experimental Technology $Subsidence Control ft ft
Geothermal(Closed Loop) $Tracer :2U'.]iI1.ILLJNGLOO(att:la: dditfopiilshheetsIfnecessa'
Geothermal(Heating/Cooling Return) $Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVroek type grain nlse etc.)
r- 6 ft Z„ti ft _—
4.Date Well(s)Completed:tp l(q 'A Well IN 2.45 ft R j O ft. f. PIG ,CL
�
5a.Well Location: Lis ft 24s ft !ety Yii41.{
Ilvaf Iwo ft ft
Facility/Owner Name Facility ID#(if applicable) ft• ft. w-
°I(�b� 5�ak, r 'CZd Sat Is ba�AK 28l�1G ft ft. -`-_ :,
Ph ical Address,City,and Zip vft ft.
County Parcel Identification No.(PIN) .- ,., +'r^3V" 'l
00: .614-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'h k'd '
(if well field,one 1st/long is sufficient) � 22. tification• l
. 5.6'1 17 N©bU. 19 W e�-
6.Is(are)the wells)JPermanent or $Temporary Signs e o ertified Well Contractor Da
B nin is form,I hereby co*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: it Yes or %No wit ISA 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 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:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a'T 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100') construction to the following.
10.Static water level below top of casing: 35 (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 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) 1 O t 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: \b 62. 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