GW1-2023-01722_Well Construction - GW1_20230213

1.W ontracforS: •motion:
_ -14..WATER ZONES ;
Well Contr for �te. - FROM TO DESCRIPTION .
ft
IAAi ft ft
NC Well Contractor Cer4cafion Nmnber
15:OUTER<EASIN�,(fo"r riurlti cased wells)Oft LINER Crfa'licabla;s
Morgan Well &Pump,Inc. FRoM TO I DIAMETER THICKNESS I MATERIAL
Company Name +1 ft' ft' 61/8/ m' sdt21 pvc
IrIN Il R CAMNG OA•TIIBING: eotiiermal rlo'sed lou' .' "`'�'
2.Well Construction Permit#: �`C� FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pernuts(ie UIC,Cotariv,State,Variance,etc) ff• ft in.
3.Well Use(check well use): ft .M 'n
Water Supply Well: 17--SCREIII',:-:.:
FROM TO DLIM=~ SLOTsIZE THICKNESS MATERIAL.
Agricultural CiMunicipalRublic ft, ft in.
5 Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft
!lindustrt Commercial Residential Water Supply(shared) ::IB:
11ri Lion I FROM TO I MATERIAL I EMP.A CEME .T M=IOD&AMOUNT
Non-Water Supply Well: o ft 20 it. benton!te poured
Monitoring, ORecovery it ft_
Injection.WeII
R ft
_!Aquifer Recharge I Groundwater Remediation �.
,.79:SAND/G 2AVEL PACK ti 'lica6le
Aquifer Storage and Recotvery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT rY 01) '
_`Aquifer Test OStormwater Drainage ft ft
!Experimental Technology 0 Subsidence Control ft ft
t Geothermal(Closed Loop) !Tracer :28.DRII211NrGSOG'(ahticli'sdditidnalsUe6,friecess y'':`l. ::•:-:s
Geothermal(I3eating/Cooling Retum) -i Other(explain under#21 Remarks) FROM ro DESCRIPTION(calor,hardness,soil/rock ty e, • sir,efe
` ` ft 0 ft
4.Date Well(s)Completed:_1 ` a� 2)-Well ID# �D. R 30
f-
5a.Well Location: ft ft •
` __. ft ft
O � ur -
Facility/Owner Name Facility M#(if applicable) ft ft. �� �l I o'1,
53o aana), :u � � �<<4.b,Y • NC- Z�bl� ft ft
Ph sical Address,City,and Zip ft ft E R
•ZI: -;-
County Parcel Identification No.(PIlq
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �6
c 2 rafion:Il�
35. loe t52- -N �O•`�.Oq� W .. 2 l ZZ
6.Is(are)the well(s) `Permanent or OTemporary SigoatK EfOgrtified Well Contractor Date
B fining is form,1 hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or MINo wuh 154 C 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a
Ifthir is a repair fill out known weD consiructon fdforrnation and explain Die nature of the copy ofthis 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 Iand surface: (ft-) 24a.For All WeIIs: Submit this form within 30 days of completion of well
For multiple wells Girt all depths ffdiffLrent(exmnple-3Q200'and 2 t@r 100) construction to the following.
10.Static water level below top of casing: �d (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
~ 12.Well construction method-rIr uj above, also submit one copy of this form within 30 days of completion of well
Cie.auger,rotary,cable,duectpush,etc.)
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Water Supply Injection Well.:Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this foim within 30 days of
13b.Disinfection typ Amount:�� completion of well construction to the county health depaitment of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources - Revised 2 22 2016