GW1--06019_Well Construction - GW1_20241011

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WELL CONSTRi7CTION RECORD (GW-1) For Internal Use Only: • 'N�t bE„___'.�
• 1.Well Co tractor Information: •
l ,.. r: "
14'JwA.i- 1;•ZONES'..:. ...:'t '',s .,.i.T., ;4J�.�.,.,.,,4.. ..?:;
Well ontract r me FROM TO • DESCRIPTIONI
' . 3acD-a- I$s ft 18'1 ft. P w'
ft, ft I I
NC Well Contractor Certification Number <,.,
•:15;:OIlTFR.CASING:(fdrmniti-ca$ed.ivells)"ORLTNER OWlicatiIo)• �i<::•.;.:''.� ??';'••.
•Morgan Well&Pump, INC FROM �TO DIAMETER TBICIQVEss MATERIAL •
. •0 ft. Q! ft •61/8 in• sdr-21 PVC
Company Name .
Sri
:1b:I VNERiCA:SINGOR4LUliIN.G`(gebthei sia1clos'ed Ieop)'::``.:'::::' ,::';":i '?:.::.>•:::
2.Well Construction Permit#: FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permi (i.e.WC,County,State,Variance,etc.) . ft ft in.
• 3.Well Use(check well use): ft ft. in. •
Water Supply Well: .•.•-" :.. ':.•• . .. -
FROM TO DIAMETER_ SLOT SIZE THICKNESS ~'MATERIAL
X Agricultdral 0Municipal/Public ft ft. in.
X Geothermal(Heating/Cooling Supply) Mg Residential Water Supply(single) ft ft, in. •
•
1j Industrial/Commercial DResidential Water Supply(shared) /iffoROTTT ,;..-.
-I Irrigation FROM TO MATERIAL • EMPL:CEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft bentonite poured
I Monitoring IDRecovery . ft. ft.
Injection Well: ft ft
*Aquifer Recharge' DGroundwater Remediation .
19:SANIT/GRA.VEL'PACIK(if applicable) :..:..: • " •:•":.
Ili Aquifer Storage and Recovery 0 Salinity Bariier FROM TO MATERIAL EMPLACEMENT METHOD
• •Aquifer Test nStormwater Drainageft. ft.
X Experimental Technology DSubsidence Control ft ft
Ii Geothermal(Closed Loop) 13Tracer :20:.DRhIJ E GLOG(attac1Iadditioiial'slieets If necesssary)":':;;':;:.^:,`.,::' ,>••.
FROMDESCRIPTION(color,hardness,soil/racktype,grain size,etc.)
I Geothermal(Ileating/Cobling Return) J) Other(explain under#21 Remarks)
ft D ft. /Vy�
ma.
,,-.4.
• 4.Date Well(s)Completed:Cit 31)-A. Well ID# � ft CJ 0 ft r`wt be-1w-
5a.Well Location: • .5� ft ft.
SC. 'b:el W w r��.
C AW\ • • 8 5- " SOa ft ty lii g rdti
Facility/0 Name Facility ID#(if applicable) ^.� _ t•-. _
2 O0\ S. �1� V�+v �1V. c4�`6hla �t�.r lJ - ft ft. '"' .. ' P' 1.
Physical Address,City,and Zip J J . • ft. ft OCT1 1 ��
&01•J In VI T:.. Mt•4`.'tit.1NR.'E7.Yv:S `- : ih•1r.;k :'.-.V r:>"^-.-Y :;:'�::, t`:;
County ._ .:
Parcel Identification No.(PIN) C '.. .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22. • cation: .
SS.?X13. N It. 2-OD A W
I i 6 I-'t
6.Is(are)the well(s)JPermanent or Temporary Sim rtified W;::L_)
Cr Date
By signing t is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or EiNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifihis 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:' �y� . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S C70 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdifferent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: SS (ft) Division of Water Resources,Information Processing Unit, '
, . Ifwater level is above casino use"+" 1617 Mail Service CenterRaleigh,NC 27699-1617
11.Borehole diameter: 6 118 (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
(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) I Method of test: air 24c.For Water Supply&Injection Well : 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: 24 completion of well construction to the county health department of the county
where constructed. f
• . 1
Form OW-i . r North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016 '