GW1-2023-01707_Well Construction - GW1_20230213

1.W ontractor Inf -meson:
14:.WATER ZONES ,
Well Con tar� :me, FROM TO DESCRIPTION
� ,/ny,` fG �G
fG ft.
NC Well Contractor Certification Number
15;OVTER---CASING,(foc multi cased webs)O,R_LII� rf IicahL
Morgan Well&Pump,Inc. FROM TO DT. R TMCMIZESs IyrATKRIAL
Company Name
+1 ft O ft 61/8/ rn sd21 pvc
J L 16 H CASING OMR OB•TUBING. eotlierrasl erased loo
2.Well Constr melon Permit#: (J FROM TO I DT MET Z R I THICENESS I MATERIAL'
List all applicable KTR construction permits(Le.UIC,Counl!K State,Yatiance,etc)- ft. ft itL
3.Well Use(check well use): ft ft m
Al
ater Supply Well: 17 SCREEN',: :: �; r;:.: ,:`.:--.ib. :;.:. .:=`•
FROM TO - DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural 0Municipal/Public ft ft in-
GeothermalGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fL in.
7udustn ommercial !Residential Water Supply(shared) .ROUT..*
: -. .. _ ,..:.:. -
E
lion FROM TO MATERIAL EMT CEMENT M=OD&AMOUNT
ater Supply Well: a ft 20 ft bentonite. poured
oring Recovery ft ft
n � M fGr RechargeGroundwater Remediation
!.19:SAND/GRAVELTA:Cr Storage and Recd'4ery (Salinity Bamer �FROM TO MATERIAL E,IPLACEIENTivLETHOD
r Test Stomrwater Drainage ft. ftmental Technology Subsidene Control ILrmal(Closed Loop) OTracerffial(Heatln�COOIin Return) _ Other FROM TO DESCRIPTION(color,hardness,soiUrock 4 sae etc)
r g ) (explain under#21 Remarks) d ft ft `
4.Date Well(s)Completed: Well ID# 5a ft �U ft C
52.Well Loczvc� ation: ft ft
��(.r.— ft ft
Facility/Owner Name Facility M#(if applicable) ft it t E �� )tl•/
ft ft
Ph sical Address,City,and
J fG ft
(oa3A 2 15 21 RrrMeuuc'
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or derimal degrees:
(ffwell field,one lat/long is sufficient) 2 er cation:
35.L 46 N (X�.��SO� W
a5 2
6.Is(are)the well(s) Permanent or OTemporary Signa frO2C
Well Contractor Date
B gtung I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existingwell: ©Yes or ®No wuh 1SAN0100 or 15ANCAC 02C.0200 MeH Construction Standards and that a
If this is a repair,fill out blown weAconstruction information and erphun the nature of the copy ofthii record has been provided to the well owner.
repair under#11 remanCs section or on the bark of this farm.
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: `� ,.�^ SUBI=AL INSTRUCTIONS
9.Total well depth below Iand surface: ZOO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For molt pre welly/Ist a!!depths ifdifferent(example-3 cJ 00'and 2@100� construction to the following.
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 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the fb=to the address in 24a
~12.Well construction method- 0 L` above,also submit one copy of this form within 30 days of completion of well
(i_e,auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount ai, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016