GW1--06539_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only: •.
- 11
edafracfora1fion: .y .. - ... . .:. '....... - .
d clt 14:.WATE)2rLONE�'. x' " t:': t..:;+`'.:::: t
Well Cont.
ct Name FROM TO DESCRIPTION !
`t�- J� 300 ft 36D- ft 3�.rw�'j '
ft ft.
NC Well Coi±sctor Certification Number • l5J.0U.k.k.R.,C4.81NG'(fdr+iniilli=cagedw6114'ORLl R(igap•liistirs)::J:;�-:g::.`•::;;.s `:
- Morgan Well&Pump, INC • FROM TO DIAMETER' THICKNESS MATERIAL • .
CompahyName 0 ft i. `_l.. ft •61/8 in' sdr-21 PVC
u` �3 :i16.7:1,SINERiCASINGCO :L'. ut3IlVG;(geottieimaLdosed-1o+op)..'':•:`::�'.'::v.: v. : :;
2.Well Construction Permit#: )-A~ V�] FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,-County,State,Variance,etc.) ft ft. in.
• 3.Well Use(check well use): ft ft. in.
Water Supply Well: i:17.:�Cft-TAN.1,•.:.• .?>: s.',.•••. •'.;.: : ...:'. :':::.1:'.•: + '....• :: ;, :
_FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
4 Agricultural )Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) }Residential Water Supply(single) ft ft. in.
X Industrial/Commercial DResidential Water Supply(shared) ..I8 GROUT:;'..'•.'::; "'µ
_I Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft 20 ft*: bentonite poured
•Monitoring Ei Recovery ft. ft. •
Injection Well:
ft . ft
1 Aquifer Recharge D Groundwater Remediation :Ig:9iSNAlGReAVEL PACK(if applicable) :.. "
4iAquifer Storage and Recovery �Sal inityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test 0 Stormwater Drainage ft ft
A Experimental Technology 0Subsidence Control ft. ft.
4 Geothermal(Closed Loop) riTracer .20:.DRI.LLIlVGL•OG:(a'ttdcf(=addidhiiSfsfieets'ifuecessar9)1':':;;::::.:1.:;;'.::.;•.;.;:',
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) .�
1 0 ft .2.0 ft j1 T-0,16 , I
4.Date Well(s)Completed:I D`4 j )--(AWell ID# , 3 s ft. b r - .sac-k.
5a_Well Location: l . 3� �pb ft t�'� _
tin C.,'(Yl1..., Ut- C YCL `a �' ft. ft G ,y' i r'
Facility/Owner Name Facility ID#(if applicable) ft ft. r J 0
ft ft01: 2024
Physical Address,City,and Zip {rD 1 r+ ft ....... , . .. .,. ..f'.a " ..' :..
County Parcel Identification No.(PIN)
51.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
1st/long is sufficient) 22.Cer' cation:
(i
q t%/l, N So-4�`J4 2 W (6 o id-9
6.Is(are)the well(s)JPermanent or Temporary Signa Ce ed Well Contractor Date
• By ring this orm,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or EgNo with 154 NCAC 02C.0100 or 1SA NCAC.02C.0200 Well Construction Standards and that a
If this 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: 00 (fh) 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: 1 .
10.Static water level below top of casing: 3D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY Raleigh,WELLS ONLY: 1636 Mail Service Center, NC 27699-1636
13a.Yield(gpm) 5 . Method of test: air 24c.For Water Snpply&Infection W
ells: In addition to sending the form t •
o
fj . the address(es) above, also submit one copy of this form within 30 days of
granulated chlorine f b`L i
13b.Disinfection type: Amount: • 1111 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