GW1--06466_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only: •
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Well Cant ct -Name �FROO�M TO ESCRIPTLIONI�
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4 � � � ft V�. ft'NC Well Contractor Certification Number -41
;1 .OU'.t:kR:•,CA81NG'•(fdrintila,Cis'e 've )ORMIEI2(i£ap•I(cable)•::':;':%%;:.1.'..4;`:;
- Morgan Well&Pump, INC • FROM TO DIAMETER THICKNESS MATERIAL •
a ft ft 6118 in' sdr-21 PVC
CompaayName •
S16'.•INNERi OR13.41 10;(geotliecmalclgsed-loop)':'`::„;::;':':,€„4v..`,;;`:;,:;:;
2.Well Construction Permit#: FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.IC,County,State,Variance,etc.) ft ft. in.
• 3.Well Use(check well use): ft ft. in.
Water Supply Well:
bTT<B•GREF,IC.,•:•;:*:•::.:2>":%:%�s�::-.,i;:s=•:.i'. +;' -.. _., .. . ,. ,:. •: h-. ;,:::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f Agricultural DMunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) 1DResidential Water Supply(single) ft ft in.
*Industrial/Commercial DJ Residential Water Supply(shared) ..IB<GROU C r`•.'.':, ':';*":'
+ 1 Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&AIISOUNT_
Non-Water Supply Well: a ft 20 ft-: bentonite poured
I Monitoring rlRecovery ft. ft •
Injection Well: ft . ft.
•Aquifer Recharge nGroundwater Remediation .19:SAN1)/GRrAVEL I'ACK(i£applicable)••: - .... '-•` •' .'
*Aquifer Storage and Recovery 0SalinityBonier FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test 0 Stonnwater Drainage ft ft
*Experimental Technology 0'Subsidence Control ft. ft .
*Geothermal(Closed Loop) 0Tracer .2D:.DRIL`J (GI:O (attach;add(fibiial-slieets'ifriecessa 9)1'.::','.:::;;;;:,..1...-..,:-.- -`'' -
n FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,eta)
I Geothermal(Heating/Cooling i Other(explain under Remarks) �� j t r0,t,.
ft
4.Date Well(s)Completed: (U(�� Well ID# C 55 ft. r��� y—A�`�
5a.Well Location: vvvvv • • ft. `
ft ft J
Facility/OwnerName Facility ID# if ap licable) ft ft. ;,... :L, l %i' L..,L)I
ebra �i,Jo �lv/ i w ��,S Z t ft. Nov 0 4 2024
Physical Address,Cit dZip ft. ft.
._ ....... �. _._J v. '
+3`. ..:_ _. ..;t:yi::. .._,�• Yr•' :t'.^^,..•,^...�:�"-' ::t�:it<''-e7,.:S':;;:;
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County Parcellde tificationNo.(PIN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
'Of well field,one 1at/long is sufficient) q 22.Cer
l" Qu � cation: �?
sylp N i7 ��g W l�
6.Is(are)the wells)JPermanent or Temporary SI5n ce ed Well Contractor Date
By ring this orm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or EiNo with 15A 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 ofthe 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:1 . SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: 2.15tZt ._(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 2@100) construction to the following:
10.Static water level below top of casing: `.3� (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 18 (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.)
1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) W. Method of test: air 24c.For Water Suiwly&Injection(Wells: In addition to sending the form to•
. the address(es) above, also submit onel copy of this form within 30 days of
granulated chlorine I
13b.Disinfection type: Amount: Ott, completion of well construction to the county health department of the county
where constructed.
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Form GW-1 - North Carolina Department ofEnvironmental Quality-17ivisionof Water Resources j Revised 2-22-2016