GW1--04008_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
• 1 Wel Contractor Information:
':14i'W'h1`Ei2?%ZO1V'E..'.'Sr. :.ic:: :,i?.:•4^,;7..'•v'14i'c' ;i "... .. .
WeIlContractorName FROM TO DESCRIPTION
90 ft 15 ft 6 rn
• 3� `� "s f 3 f` ip9 ti,
NC Well Connector Certification Number 5::6 ER G:(fdrmulti. a.yYe1Cs)GRIME(tf ap livable):t: .:Z:h.o.,.:r:.`•..
•Morgan Well&Pump, INC • • FROM To DIAMETER THICKNESS MATERIAL .
0 R' 52,. ff. •61/8 in. sdr-21 PVC
Company Name
�„ 11 ^„1 f.1Z1f�TER:CASING"oR-ir[FBll�(G:(geotpeimalelosed-loop}:::''.: ::::,:' ::, . :;;:::
2.Well Construction Permit#: 1-6Lyn'(`�}`(' C2\ FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) R. it. in.
' 3.Well Use(check well use):. ft ft in.
'f17.scJRHEN:4..,.. • .:;a Z G:. %:: � :". F.'.. • ''i;=r;:tY,::`• .:i'?'t:,liir
Water Supply Well:
FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
• )i Agricultural ElMunicipal/Public ft ft in.
X Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) ft, ft. in, .
a Industrial/Commercial )Residential Water Supply(shared) :'IS.'oROUT,:;.•::'•. ',,,,"'•' •.. .. .
_I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. bentonite poured ;
X Monitoring Recovery ft. ft. .
Injection Well: — ft ft - --
Aquifer Recharge D Groundwater Remediation
.19:SANIY/GRA'VRL PACK(if applicable). .: ,...••s::.• :::::.. •
Si i Aquifer Storage and Recovery 10Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test 0 Stormwater Drainage ft. .ft.
X Experimental Technology rj Subsidence Control ft. ft
X Geothermal(Closed Loop) nTracer .:2O SI B(GL( (attacliadditional•sheets'ifnece'ssa y) :.`::;;:::::":::::'.;
FROM TO DESCRIPTION(color,hardness,soNrock type,grata she,etc)
Geothermal(Heating/cooling Return) n Other(explain under#21 RemadLs)
•
�t �, C ft a5 ft )rol�ah C W t
4.Date Well(s)Completed: t A n)- ' Well ID# - _ ft b ft ��f or r c_
5 Well Location: 1✓ ft AZ Y r"►v {,\.L
`Ln`_ tt ft �tr e` ,i
Facility/0 axe" T a Facility ID#(if applicable) ft. 0 \rv..`,I : `'r
54$ earl �ai3 'Dr. New 1 ar,rir ZZ I.a�1 ft
JUL d 8 2024
ft. ft
Phys Address,City,andZip 7 ���Q��
O .�rOI i t `1" „ra".-Oio ?� 2tumur r. • '•:50. ; .x:Nt.:: :ovriii `�r�th:;."`:. :gti .:.
County ( Parcel Identification No.(PIN) DitiC3l�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. cation•
3'5. A!.°Is C0
N 1 . i I(oc. W �/ 6 _.a-11
6.Is are the wells Permanent or _I Tem or Sign o edified Well Contractor Dfte
B in is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or ffiNo • wz ISA NCAC 02C.0100 or 1SA 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 fonn.
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 neceecary,
wed:' SUBMITTAL INSTRUCTIONS
• . 9.Total well depth below land surface: .P-0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfferent(example-3®200'and 2®100') . construction to the following:
10.Static water level below top of casing: 40 (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:
(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) /5" Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: D 0,�/ 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