GW1--04713_Well Construction - GW1_20240812

.
WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: '
1. Contractorww ormation:
IOM ':14.:4Attp;:ZONES:;. `..'t ::;? `:'".fir-::2:::..':'�J: i.,: ..t:[.:::,
Well 2C`on�• tor Name p FROM TO DESCRIPTION
• J't ti% l i 5 ft. Ill f' V1'^
NC Well Contractor Certification Number /IPS ft. 14g- t1 q 1Yet15r:UT3` 11,.GASING:(fd hibid, ediiialls)'ORLI15IXR:UP linable):•K:::Z.:r; `:;:;,>:;`".
Morgan Well&Pump, INC FROM TO DIAMETER THICKNESS MATERIAL •
0 ft /0 f ft 61/8 in' sdr-21 PVC
Company �`Name
.C16' iblER:CASING 91VrU$IlVG:.(geottiecmaldosed-lo.p)•::=.. :: ....:;!:...
2.Well Construction Permit#: WW I''� (�14, 544ot3D FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
ft •
3.Well Use(check well use): in.
17:SCREE,N:?•.':::ri.t; '::-.; , .,..,_..:„*::::. . , ..,...r
Water Supply Well: .:a:`:.,:r:..: ..: ...<..:. ..:
FROM. TO DIAMETER SLOT SIZE THICKNESS v,MATERIAL
Agricultural laMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft R. In. .
•
Industrial/Commercial EIResidential Water Supply(shared) ;:• •:.Ib�GROTJT' : . . .. .. ....
_1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft 2c ft bentonite poured
Monitoring EtRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge fl Groundwater Remediation -
Storage and Recovery19.SAND/GRAVEL.PACI((If applicable) :..: .: '.... '-.... . '
Aquifer g f Salinity Barrier FROM _ TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fl Stormwater Drainage ft. ft
Experimental Technology ri Subsidence Control ft. ft. •
Geothermal(Closed Loop) [Tracer :20:3fRi'GliO LOO attach"additiouai'sfieets'if6ecess ' -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(calor,hardness,soli/rock type,grain size,etc.)
avek
4.Date Well(s)Completed: Well lD# '1/s ft- S ft. _
5a.Well Location: rr5 ft' ya ft �Y l (/ �„�
x�C 96 f �I 5 f' blue. C }O-� ... �. " .
Facility/Owner Name Facility ID#(if applicable) ft ft -t i...../.t... V 7,.,L.
l S5 SlIef4erd 1/4 14 Rd- iniaeiSK ll& NG ZsiL5 ft. ft.
AUG 1 2 2024
Physical Address,City,and Zip / �r JQ� �g
e-l t `6Q.— GA ~ T O-7 2'�.:1ZEIoloo._-, ',n.,.`:; 'iiV`.' Y:�tY-fs,::-. '4kq yjTi,y a' is;;,:,
County Parcel Identification No.(Pill) LA I.i"'t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one le/long is sufficient) �.� Q1 j
• cation:
wN . O.-12, W 11/ 46/ 91,
♦ L
6.Is(are)the well(s)0Permanent or EllTemporary Si...1
-oartified Well Contractor • Date
By signing form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A 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:' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 •
(ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-33@2200'and 2C4)100) construction to the following:
10.Static water level below top of casing: 15 (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) /J! Method of test: air 24c.For Water Supply&Infection 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: 9 arcuated chlorine Amount: OZ 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