GW1-2023-01404_Well Construction - GW1_20230208

I.Well Contractor Information_ L
I
•14:WATERZONES
OM TO - DESCRIPTION. _
'Well Contractor Name � V � ` �
fL ` jt i
NC Well Contractor Certification Numbet
15:OUTLR-QASWGX:05r mnld&dised i'vm.$)
Morgan Well &Pump, Inc. FROM I To DUMETERI I s azA Td7•
Company Name +1 ft ft. S ilal i sd21 [PVC
P Y . Ito P 16Il�IIZES2CASII�TGOR•TIIBING:' edtliermAlclusedlod`?.;:,"-'-
2.Well ConsfrnctionPermit#:w l►�� .4bVV �iro� FROM TO DTdMFTFR I THICBNFSS MATER7Ar
List all applicable well constructionymmits Le UIC,Carartv,SYate,Pj'v!w e,etaf ft. ft. '
• 3.Well Use(check wen use): ft. hLI
Water Supply Well IVSCREW'•=:.:: t _ .` _•�:ER :. IZE . .; :•:L• t�::.:. _:::`
FROM TO "DLj.Lj '.:SLOT S -THICKNESS IYIATERTAL
Water
QMunicipallPublic ft. ft in-
Geothermal(Heating/Cooling Supply)' a2esidential Water Supply(single) ft, in-
IndustriaU t=Y
Commercial Resideutial Water Supply(shared) GROUT-.`-•
IIrri 'on FROM TO MATERTAT. - BTUjACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o fL 20 fL bentonite• Poured
Monitoring ORecovery ft fL
Injection Well:
_Aquifer Recharge DGroundwatar•Remediation R fL
Aquifer Storage and Recovery I a]inity
S Barrier FROM TO MATERIAL EMPI ACEMENTMEfHOD
Aquifer TestlStomrwaterDrainage fL ft
E,-perimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) OTracer :ZO.DRIl�QGZOG'(attiich=additiousl slieetsjfrecess-7'': =._ :_ •:' :-
FROM TO DESCRIP ON(cold,hardnes,so type,gain site,etc.)
(Geothermal(Heating/CoolingRetum) j Other(explain under#21 arks) tti `rV
4.Date Well(s)Completed: WeIl ID#/ ft ft-
iuol
5a.Wen Location:
Facrlity/Owner Name FacilityM#(ifapplicable) �} ft it Li
r (� t
Physical Address,City,and Zip ft.a __ kM� r i 1'" q_t _
County Parcel Identification No.(PIM I FEB d 5, 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field onelat/iongisSufficient) 22_Certification: i 1, WOUZ0Li
6.Is(are)the well(s) iPermanent or Temporary Signature of Certified Well Contractor i Date
�° b By signing this farm,I hereby certi that the,weII(s)was(were)constructed in accordance
7.Is this a repair to an existing well• Dyes or°41 No with lSA NC,4C O2C_01 DO or l5A NC.IC 02C,0200 FYe.0 Conshwction Standards and that a
IJrhis is a repair•,frU ouf known well construction biformadon and explain Uie naim•e of the copy ofihis retard has beers provided to the well owner.
repair under 421 remarla•section or on the bark of fiVs form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Qosed-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 TOTALNUMBER'ofwells construction details. You may also attach additional pages ifnecessary.
drilled_ SUBMITTAL INSTRUCTIONS I 1
9.Total well depth below land surface: (ft) 24a.For All Wells: Submit this foam within 30 days of completion of well,
For multiple wells list all depths ifdiffler ent(ermnple-3 200'�DO, iv ;
construction to the following.
10.Static water level belowtop of casing: (ft) Division of Water Resources,Information Processing Unit;
-Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
I ,
]I.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to(1 sending the form to the address in 24a
12.Well construction method L` above, also submit one copy of this form within 30 days of.completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,etc.) -
ONLY: Division of Water Resources,Undergl ound Injection Control Program,
FOR WATER SUPPLX WFS LS
_ 1636 M2il Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) Method of test: all pressure 24c.For Water Supply, Infection Wells: In addition to sending the form to
�,1 the address(es) 'above, also submit one copy of this form within 30 days of
I3b.Disinfection type:_ rCJry�Of Amount completion of well construction to the county health department of the county
where constructed_
FormGW-1 North Carolina Department ofEnvimnmental Quality-Division ofWaterResources - Revised2-.22016