GW1--04701_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Contractoration:
0 '.;24.kviiVER ZONES ...;'Si.i -
Well Con tor Name
FROM TO DESCRIPTION
R Ito f, t i ft • Su'+fi
NC Well Contractor Certification Number 345 ft. ` G am
ft ,5 'r ,
t15 R:bu E ..GA 1 SIINOG:(for.mnitL 4ed.*iiii)oRIdAiRR atiii lirapte)_::;.,e.•. ::.a':,'.
Morgan Well &Pump, INC FROM _TO DIAMETER THICKNESS MATERIAL
0 ft. ft- 6118 in. sdr-21 PVC
Compahy Name vJ D
.:16:Ib1NER:CASDIG.M [}BING.(geottiermatclos d-loop):: ..f.';: :.,,&•:',.: ;:.::;;:, -
2.Well Construction Permit#:05W P-2.o4-44- 4 "n( Z i 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
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3.Well Use(check well use):
ft. ft. in.
Water Supply Well: FROM. TO )DIAMETER^�JSLOT SIZE THICKNESS MATERIAL
__Agriculttiral DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) IMResidential Water Supply(single) ft ft tn.
_ Industrial/Commercial DResidential Water Supply(shared) oRitym ::.(..•-, ,-
:1In-igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft' bentonite poured
Monitoring EIRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge flGroundwaterRemediation
19 .. .. .
.3ANII/GRAVE.)',PACK(d a plicahle) :..•' . .
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
jAquifer Test D Stormwater Drainage ft ft
japerimental Technology nSubsidence Control ft. ft
)Geothermal(Closed Loop) D Tracer :20.1:11tIL•Ir G LOq(acts tiradditioual sheets if ueces any)'::: :.:is'.!'•: ;'::
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,ete.)
.Geothermal(Heating/Cooling Return) father(explain under#21 Remarks) O ft Zd ft
•
- 4.Date Well(s)Completed: 7/I7/Pi Well ID# 20 ft. „ d ft. tY n Atck-
.
5a.Well Location: ft' 7e/ ft' 'YOLK 1 cHa
7 ar- r'l SO ft' 385 ft lest L—c troaNt - -.7 -- - _
Facility/ l Facility ID#(if applicable) ft ft '--'-4'L. - f Li
4455 / oci-q 3)a I I'Y)frrt sot We. ILA 211!5- ft ft. AU 2( 1 2024
Physical Address,City,and Zip
-reeAtA, gbbS- 5 7- 2.z9 9 : - _ < ,, . ::,5<; ►: „h.�, ,, r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22. ' ';o cation:71 _
35 £ -+�5 N O.7995 w �G�L/ /d
6.Is(are)the wells)jaPermanent or Temporary Si.,.�I 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 )No 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.
dulled:' - . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 8 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@2200'and 2@100) construction to the following:
,
10.Static water level below top of casing: T 5 (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:
(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 3
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: 15 •x 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