GW1--04798_Well Construction - GW1_20240814

,t ' 'tot_' i y_-;7;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: • •
1. Contractor formation:
:�,4:yV�1'ER:ZOPIFS:..;:• ,.,.::;...:c<,a. �'>_`::�`:i '*Cl;•'r:.:">";z'l;r;‘:ri:i4''!� x.,,.:
Well Con torNamep FROM TO DESCRIPTION
?s� R 115 ft ill it 1 O 45pw'
ft. ft
NC Well Contractor Certification Number
afi,':OUTERCASINGIformiilti-eiaed.ilelii)ORLIN=(ifaPpOiiadle) <a� .
Morgan Well&Pump, INC • FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. ft 61/8 in. sdr-21 PVC
Company Name (�, p��{L.
�.....,..;;..
�4 r 1� ' .16.'ININIER:CA G.ORlL-0 9G;(getitl etmalelosed-loop).`:"..:. , :•..;:c':.:;':; :':: '
2.Well Construction Permit#: !/ FROM ' 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): it' i°'
Water Supply Well: z17 SCRSFd`i:: s:.:;. :'.:: ; R. .,.>:..: .. ...k<.:::"::;:':;:..:.t:'.::' :.
FROM• TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) im Residential Water Supply(single) ft ft. in.
Industrial/CommercialD Residential Water Supply(shared) :.iff GROUT-'`. ":••, '. . ... ., ..
1 Irrigation FROM n. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 2ji ft bentonite poured
Monitoring ORecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation . .
. .. ...
19:SANl?/GRAVFd.PACK •
ID Aquifer Storage and Recovery f Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f Aquifer Test 0Stormwater Drainage ft. ft
_!Experimental Technology Subsidence Control ft. ft
J Geothermal(Closed Loop)p) _ Tracer 20:.I)RILirilifGLOG(a'ttscti"additIonal'Sheets"iCnecesary)'::::: :_': :'::,C:' `. :4'';:':
i FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,eta) •
Geothermal(Heating/Cooling Retum/).�l Other(explain under#21 Remarks) O ft. ft. d a�
4.Date Wells)Completed:7�g/�T Well ID# ft. 5 ft. �C.D (1 IA.
«(5a.--Well Location: ,15 ft. 45 ft
location:
/Rk' LI wi'1 U5 OP i6 �j ft aD.4545 ft. tut.
ut a
Facility/Owner Name Facility ID#(if applicable) ft ff
R
'`5- ArcAt-e. Lr r lalnl 'A/C 2�1I;-- ft. '� -� � s
Physical Address,City,and Zip ft. ft. "�'11] L 20e4
UhloH O►'--jam--e(' .21-I . ti..,,. ,
County Parcel Identification No.(PIN) r * rL. 'a I,J,1.-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. e 'ication:
34 . O t t N 10. �C?-3 W � 7
6.Is(are)the well(s)JPermanent or DTemporary Sian e 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: fl Yes or ffiNo with I5A NCAC 01C.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: p45 (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'and 1(4100')
construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 D 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: granulated chlorine Amount: 8dz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016