GW1--06082_Well Construction - GW1_20241014

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WELL CONSTRICTION RECORD (GW-1) For Internal Use Only: : '
• 1.Well Co tractor Information: . - •
,1;4fAV24i'1!4CZONES.". . . :011::;` I >'•i:....-' .c`q'cJ.'•^: .>i �•;:
Well ontiact r me FROM TO • DESCRIPTION
ft ft i
NC Well Contractor Certification Number '
IS::OUYBR.,GQSING:(fdt',mniti Cis-ed.Wellsf'URT,TNER(if tiP liCilile)•;;';r.> ::::::l.':
• Morgan Well&Pump, INC • . FROM PTO DIAMETER THICKNESS MATERIAL '
0 ft, q5 ft •6118 in• sdr-21 PVC
Company Name - 0
���h�r 16•'INNERiCAiSING OR:TUBING;`.(geo'tliesmalcles'ed-loop):::`...: .:';`•:..;1.$.,; •.;r•a.:
2.Well Construction Permit#: ` `v9 FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable Well construction perms(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
' 3.Well Use(check well use): ft. ft. in.
• 17 GREEN:••!i:;>•::::.;::::•:%.'s:• ••` -•..: ''%x�'.:.:.•
Water Supply Well: ,I: •HI KN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultdral 0Muninipii/Public ft ft. in.
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QGecthermal(Heating/Cooling Supply) le Residential Water Supply(single) ft ft in. •
)Industrial/Commercial DResidential Water Supply(shared) I8'<GROUT .:�: -
fIrligation FROM f TO MATERIAL•.• _l. t EMPLACEMENT METHOD&MOUNT
Non-Water Supply Well: o ft 20 ft, bentonite , poured
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Monitoring Recovery ft. ft .
Injection Well: ft. ft
Aquifer Recharge' EI Groundwater Remediation
19:SANDJGRAVEIIPACK(if a licable '.'
Aquifer Storage and Recovery Ell Salinity Barrier FROM To MATERIAL • EMPLACEMENT METHOD
• Aquifer Test 0 Stormwater Drainage • ft. ft.
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) 0Tracer :2o:.DIFTL•L•IlvG`Loa(dttechadditionalei&ts'ifriecessaiy)";':;: ; ::^:,4:::`,
f 1Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotllrocktype grain size ere)
I Geothermal(Heating/Cooling Return)
$(3O1 )I
4.DateWell(s)Completed: Well lD# 15 ft- nAt ft' 'b'�Y p� atlfr—lr
Sa ell Location: uft- ;es W L�
im ro ..
. L ft 4 J�
ear �. � or�`bt`� 25 ft 34AS ft r r&ham.
Facility/Owne e Facility ID#(if applicable) f ft' 1 •
L.J,D V LtdActdC P I 'WYfirU3 , NI V O'iOd'l g ft ft. . n'.. J.,:
Physical Address,City,and Zip ft' ft
Mil d l� .. . . . . . .. . .,,. :.. -v N
y���l V •• � .-12:T1rifARTC•C.:.= ic•'..e:•i•�- t ..� �� .... i.v:
County Parcel Identification No.(PIN) :s=� Y;i s : 77 ...`,,,R:_ fR
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Liles.,,-t,..�
(ifwelllfield,one lat/long is sufficient) 22. ' cation: '
35.1°.Ce,1 N 1v.9ecm w 1 .
)-t j0Lt.
, Si rtified W o Date
6.Is(are)the well(s)MPermanent or EITemporary
By signing is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or ffiNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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:l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3'v ) (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 00'and 2@lOO) construction to the following:
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10."Static water level below top of casing: SO (ft-) Division of Water Resources;Information Processing Unit, '
. ' Ifwater level is above casino use"+" 1617 Mail Service Center,t Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (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) IA Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
2 the address(es) above, also submit o ,one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: 1,J e a completion of well construction to the county health department of the county
where constructed.
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Form GW-1 . - North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016