GW1--06484_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only:
• 1.Well Contractor Information:io 7 •
• J 4A L `G FI L�^l ev-tei 4.SVATr�'LONES 5 is : :is.< 3.4`.'1:•. ,;R':t...'s'"r=;.... r.;, 'S... ,
FROM TO DESCRIPTION I•J
Well Contractor Name
y g'S-C.A 3g1.ft. 1 gift. 549 .+
NC Well Contractor Certification Number • 151.01F ERGQ;SING'(for m`u"lli.•cia-41 Wells)•ORT,TNE12(if ap idealize):_`:;v:%':?::_:...`::
Morgan Well&Pump, INC FROM , TO DIAMETER I THICKNESS MATERIAL •
0 ft 76 ft •6116 in' sdr-21 PVC
CompahyName ..•.. -
r- y�' ,<';16:•7NNE1tiCA;SING:.AR:TIIBIN0;(geutTiermal closed-loop}'.:::`:i.:7;•• I U;.::�:;;a:.;;
2.Well Construction Permit#: 10017 7V FROM - TO DIAMErl.'lt THICKNESS MATERIAL
List all applicable well.construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
' 3.Well Use(check well use): ft ft. in.
.,..,:
Water Supply Well: "" ""
FROM TO DIAMETER SLOT SIZE TIICKNESS MATERIAL
I Agricultural 0Municipal/Public • ft ft. in.
•Geothermal(Heating/Cooling Supply) }Residential Water Supply(single) ft ft. in.
1.Industrial/Commercial }Residential Water Supply(shared) :. 8lGROTIT :,?: ..
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ff• bentonite poured
I Monitoring r Recovery ft. ft.
Injection Well:
ft. ft.
I•Aquifer Recharge }Groundwater Remediation - I .
:19.HAND/GRAVEL•PACK(gapplicable)•- ::•
•AAquifer Storage and Recovery }Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
II Aquifer Test }Stormwater Drainage ft. ft.
I Experimental Technology }i Subsidence Control ft. - i ft .
•Geothermal(Closed Loop) }Tracer .20:.1)RIPSdNG:I.ots:(.'[tach additional-sheets'ifnecessaty);:,'r;::::-:l.::. .::;;::'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
.Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) �.y /
O` Z/� L U ft .46
/C�ft /et 4,�
4.Date Well(s)Completed: / Well ID# 6a ft yzd ft• &r C k-4A,17e
5a.Well Location: ft ft
•
�Ac4 `Ale, Ln1i✓ Iev ft ft. U''�.;.,-,--�.:,` :' ° 't,e,1
Facility/Owner Name ll Facility ID#(if applicable) ft ft.
l�cS JC�hli .C4ei,F1/N C4# - 1e l'L ✓V''//G ft ft. NOV 0CGL4
it
Physical Address,City,and Zip ft ft. lt.``•.;r..r .-f' •r:-:r •i..`
//Art]e4 bwif •.-'.: .. .,._.
County Parcel Identification No.(PIN) •
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,,one lat/long,is
sufficient) .—p g// 22.Certification:
3 S, l5-03)% N G// W (�
�� rou—z /
Si .•a of edified Well Contractor Date
6.Is(are)the well(s)0Permanent or }Temporary .
By signing this form,I 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
Ifthis is a repair,fill out known well construction information andexplain 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 faun.
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: ?IC (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdifferent(example'-/
3@200'and 2@100) construction to the following:
7 10.Static water level below top of casing: ( (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
6 1/8 I .
11.Borehole diameter: (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,l Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: air • 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit duel copy of this form within 30 days of •
granulated chlorine
13b.Disinfection type: Amount: 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