GW1--04004_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(.GW-1) For Internal Use Only: •
• 1 W 1j,Contractor Information: •
' %14 WA 'ZONES.".; s i,' :. C: ':." y .. %: ",s,:„
FROM . TO • DESCRIPTION
Well Con rD(ame $S ft- 90 ft 50
9r
• 3� -A f. f.
NC Well Contractor Certification Number '
'15.:lI ER�GASIN6:jfd itift gists-ed:004OHLINER(ifa livable) :;,: .:;;::1>:;':,
• Morgan Well&Pump, INC - • FROM TO DIAMETER THICKNESS MATERIAL '
0 ft. C � ft •61/6 in. sdr-21 PVC
Company Name .`I¢:$i14/aU GORri**r.G;(Reottiecmaliloal!d-loop1`.::'`: ;.::';•:;€;SC.: :;k::,i;
2.Well Construction Permit#: •
20 .-4 0OCADOA \ FROM • TO DIAMETER THICKNESS. MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft• ft• in
• 3.Well Use(check well use): ft in.
Water Supply Well:
iI72.S :4':..? a1.::•:�';rv:+i•.5`21':..:2. �.. YY..•.'.M1:`.':�:':•: V, "
,.•��..f.
FROM TO DIAMETER SL•TSIZE .THICKNESS MATERIAL
• Agriculttiral 0Municipal/Public it. ft in.
•Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft. ft. in, .
0Industrial/Commercial DResidential Water Supply(shared) ,:I8..:0ROpT;:'•:.,:_ ",er"' ,':•,:. ..,..;.:.`.;7';':: •• • :.
J!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft- bentonite poured '
DI Monitoring Recovery ft. it.
Injection Well:
0Aquifer Recharge D Groundwater Remediation
ft..19.SANI>JGRAVEl.'PACK(if applicable). :.. .: •' ' „.
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft• .ft.
DExperimental Technology n Subsidence Control ft. ft.
0 Geothermal(Closed Loop) [Tracer 20:31111IELINGlAW(ahsklradd tiopil'stieetsirnecepary)': ,
fl Geothermal(Heating/Cooling Return) ril Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack type,grain she,etc.)
..��''ll
6 it 15 ft irotvh dw t
• 4.Date Well(s)Completed: 2 /a4 Well ID# 15 ft' 5 ft ( MAh r6C-
5a.Well Location: ft Sft- ' Y _
vU ^ Af ‘ ft ft. _ _ .
Facility/Owner
/N�aame /� ,,, Facility ID#(if applicable)
1 ft ft ; \` LI ti '
�1T l �t CA a1S C..rcvi �y�rLIYC� ft. ft. ` �f
Physical Address,City,and Zip-ZAWALti V`'� • ft ft J U L J 8 2024
toAr` (WWW457
48�V ��i"2fT��. :.. . ..:tf-i,...<.�:: ?k y = 4 N�.�s
`6r:,�
County Parcel Identification No.(PIN) D'f, •�'.l.rs
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �h 22.C • cationt...7
35.S33a— N OOP OSO0 W W-413/49Lie
6.Is(are)the wells) Permanent or JI Temporary SB ini n e o edified Well Contractor
is form,I hereby cent,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or ElNo ' with ISA NCAC 02C.0100 or ISA 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.
wed:t SUBMITTAL INSTRUCTIONS
. 9.Total well depth below land surface: (t6 (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'mid 2Q100') construction to the following:
10.Static water level below top of casing: 3S (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 Infection 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:
(ie.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..4 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: J erz 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