GW1-2023-02157_Well Construction - GW1_20230306

won Contract r ormation:
\ 14:.WATER ZONES ;_
Well COe or Name FROM TO DESCRIPTION
ft ft.
?� ..✓ ft ft.
ell Contractor r Certification Number
'15:O U;CJtR,QASING,(for mnlfi=rases wells)OIt 1dlI'ER(if ara licalile)'1 ::`:.;�•.'.-
Morgan Well &Pump, Inc. : FROM TO' DIAMETER' THICKNESS MATERIAL
Company Name +1 ft• 6. ft 6 1/8/ in' sdr21 pvc
16`INNER CASING OR•TrEING`(gedtliecrma1'cio'sedlo6p)i.: -.•_• :-;%''•':.r•: :
2.Well Construction Permit#/: eC \ 0 -Lx.. FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction permits'(i.e. UIC,County,State,Variance,etc.)• ft ft. . In. .
3.Well Use(check well use): ft ft• in.
Water Supply Well: . 17-"SCREEN, . .,. -�. . . .•_.: . - ... ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
*Agricultural EiMunicipal/Public • • ft ft in.
.Geothermal(Heating/Cooling Supply) T Residential,Water Supply(single) ft • . ft. in. _
NIEdustnal/Commercial OResidential Water Supply(shared) ::18:GRoUr.::. ,.:: . --:,' °':.::•-'
Isigation FROM TO MATERIALEMPLACEMENTMETHOD&_MOTJNT
Non-Water Supply Well:
Eg ft. 20 ft
bentonite poured
Monitoring Recovery ft ft. .•
_Injection.Well:
Aquifer Recharge Groundwater Remediation ft ft.
0
Aquifer Storage and Recovery Salmi Barrier :.19:SAND/GRAVEL'PACK(if applicable)'-:, _':,:<:'. :_'•:..... "�';• '••'..•: •:'.:..:.:•*.ty FROM TO • MATERIAL • E,YIPLACEMENTMETHOD
Aquifer Test QlStormwater Drainage • ft. ft. .
Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) DTracer . :20.DRII.LING.LOG'(attacli'additibaalsheetsifaeceFsary7•':.� '•:'=s
Geothermal(Heating/CoolingReturnFROM TO DESCRIPTION(calor,hardness,soil/rock type,grain size,etc.)
r. ) 'ccam� Other(explain under#21 Remarks) b.ft ` ft •
4.Date Well(s)Completed• tT Well ID# ft 4:S ft � , \ d ,
5a.Well Location: 5 ft 5a) ft. A6 `per c f*e.
a .ft. ft
Facility/Owner ame Facility ID#(if applicable) ft ft. w ,. ,%
1. !� �:V. L,,, (Pi ,� \I a1p 1oi c,2,s1, 3 ft ft h�n R..� V ..
:. ,uLJ
Physical Address,City,and Zip ` ft ft
� ,\k, (Ati3�. (`"...cr '.21ER-1MARKS'.".... ..' .-:i'. . ..._..-".�.. r r-:: :7':•-":--
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 2 .Certification:
''' S: cc.got-L -N <ii-.., 0-1,q -' w ' cq
160.)-
6.Is(are)the well(s)k iPermanent or QlTemporary Si...... �Certified Well Contractor •Dat
B is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or JNo with 154 NCAC 02C.0100 or 15A 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 ofthis record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
• 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: • SUBMITTAL INSTRUCTIONS
•
9.Total weII depth below land surface: 5C3C) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(sca 3@200'and 2@100') construction to the following.
10.Static water level below top of casing: °,.J (ft.) Division of Water Resources,Information Processing Unit •
If'woter level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.Borehole diameter: 6 3_(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.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 2 769 9-1 63 6
13a.Yield(gpm) 4 • 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 typrIA kbitkilt, Amount: completion of well construction to the county health department of the county
where construtted.
Form GW-1 • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016