GW1--06493_Well Construction - GW1_20241104

:`Pointf:661;r
WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only:
1
11 emitractor Info ation:
s ()vlck .:44`WATEa✓LONES•':::: i` :.1<ti :':':.. : :{.•. :".;:.: ':;t:t;:•;' :"!;
Well Cant•at -Name FROM TO DESCRIPTION
—
34 -- -A il�s ft ft ktyg ft ft. 1). `� '' •
•
NC Well Contractor Certification Number ' •15;.0li9;BR;.0 SING•(form'u"(ti4iieclfeI1s)•ORU R($ap licatile):_':&•:% :ii:;:_
• Morgan Well&Pump, INC • FROM TO DIAMETER. THICKNESS MATERIAL '
o ft '126
ft •6 1/8 in* sdr-21 PVC
CompauyName
t�, il✓ ,i16•INNER:CASINGOM.TIIBAIG;(geolliennalclbsed-loop)::':: `:;::;`.:,.?:v, ;:`;;,';;,
2.WellConstructionPermit#: /IY,La3 FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
' 3.Well Use(check well use): ft ft' in. -
Water Supply Well:• il7t.5eR10EN: •:::'*•:".":.?::2 4.,., .::'.. .' ;'. :::'<:•::.t• :..:,..`,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
RI Agricultural EiMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) NOResidential Water Supply(single) ft ft. in.
Ir Industrial/Commercial )Residential Water Supply(shared) :.I8 GROUx '•.'.':,;
Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft: bentonite poured
]Monitoring Di Recovery . ft. ft. •
Injection Well:
ft.
g•Aquifer Recharge Groundwater Remediation ft.
:19.SANDIGRAVEL'PACK(if applicable) • .:.: "'
siAquifer Storage and Recovery 0 SalinityBanier FROM TO MATERIAL EMPLACEPAENNTM'ETHOD
IA Aquifer Test jStormwater Drainage ft ft
*Experimental Technology InSubsidence Control ft. ft.
Ii Geothermal(Closed Loop) EjTracer .20:. t (' i-a. '''•'- ' ..-' t)`•:r"DI2II:S3N�OG:'aftdc-additional'sfieetr'it-necessa" ._,
Geothermal(Heating/Cooling Return) )Other(explain under#21Remarks)
FROM To DESCRIPTION(wlor,hardness,soillracktypegrainaloeetc.)
ft ckC ft 'br �0, �.
4.Date Well(s)Completed: @(' \\' VelI ID# A ft , ,�_,y J ft b r-�W y, .roc.—k
Sa Well Location: ' 1 ft \ `�L c t-{,
Facility/Owne mee Facility ID#(if applicable) ft ¢ n.t1 Y
4''C. k Doi ' s�e I 2-` 40 ft ft Nov t, LOZ,�
Physical Address,City,and Zip 3 ft ft.
ROUE A : i i �:, , ry . . .- ,. .,,.- .,..,...-. v:,. . x, ..^
..... ....:
County Parcel Identification No.(PIN) t'°`" -`3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•
.(if well field,one latilong is sufficient) 4.016D 22.Cer cation:
YDL . N t W ( ---
6.Is(are)the wells)JPermanent or Temporary Siva Ce ed Well Contractor Date t�~}
- Bye ing this aura,I hereby ceris y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or EiNo with 1SA 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:' . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: elb (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(eranple-3@200'and 2@100) construction to the following.
'50 10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casino 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:
(Le.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) `a")- Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to'
. the address(es) above, also submit one I copy of this form within 30 days of
granulated chlorine
13b.Disinfection type: Amount: 4.irOZ. completion of well construction to the county health department of the county
where constructed. 1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016