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Home My WebLink AboutGW1-2023-02160_Well Construction - GW1_20230306 • -...-.- ..........L,....,.....,,....".......-1_,._,J.1.c,DA_A._1.[C_IJ tl...1-ini-.1 t 1 For Internal Use Only:. • ' • 1 1.W ontractor In! •mation: • ' ,' .• ' . . • : Well Con tor ame • • FROM TO DESCRIPTION • ft. ft. °.. (42,•Z, ...A i „. V ' '' • NC Well Contractor Certification Number ..\ . - • .'15:0 u..1.F;R:C-4.53T,IG,(foi ranitiZrbis'.eft walls)OR LINER(if ap'lic..i.hle)%:;:::::':::::1' Morgan Well&Pump, Inc. . FROM TO' DIAMETER THE:IL-NESS MATERIAL Company Name +1 ft 51 ft' 6 1/8/ ' '1'1. sdr21 pvc , - 1 _ 16:1\TAER CARTIsIG OR.I.U.SE .(06tliefinal'616Shd.-166ii)!.;',:-‘'•:-.'it;.1'';.:1•'•... 2.Well Construction Permit#: MLA FROM TO DIAMETER, THICKNESS MATERIAL' . List all applicable well construction permits'(i.e. WC,COW*,State,Variance,etc.) ft. ft. . in. • 3.Well Use(check well use): ft. ft. in. . . • Water Supply Well: . . . 17:SCREEN'..>:...';:.:C:, .....,.;%.•:•:*.....--:.::,:r:..',...:*2::: .1::-f,.:-..7,•:'f•:..',....I.1...7:-4.:::.:.•...:-1' .:,- FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL. Agricultural 0 Municipal/Public ' ' ft ft. in. ,. I Geothermal(Heating/Cooling Supply) fiik.esidential Water Supply(single) ft. • - ft. in. I EaustriallComraercial ]Residential Water Supply(shared) ...:18:•GRODT-:,.-.:l '.-_-."'.:".s''•••,••-•:::l:?•::_r••'..,..F.•:---.•-•-.•••I:'-'l'.:,.::-.;':',,. ..."-",--•••••-••/:.7.`'-,i!':•• blnigation . FROM TO ktinzarAL EMPLACEMTNT METHOD&AMOITNT . Non-Water Supply Well: o Tt• 20 ft- benionite• poured Monitoring EiRecovery . ft. ft. . • _Injection.Well: Aquifer Recharge D Groundwater Remediation ft ft. • !.-19:SAND/GRAVELTA:=(if applicable)-•:•.:••-..-''-.1.'-•:.-.. :_'':..........-T-,''I.'•':•.•-:',...:''.....- Aquifer Storage and Recovery 10 Salinity Barrier FROM TO • 1 MATERIAL • EMPLACEMENT METHOD • Aquifer Test DStorrawater Drainage ft ft. . Experimental Technology 0 Subsidence Control ft. ft Geothermal(Closed Loop) D Tracer . . :20.:DRILUING.LOG'attiC.Ifidditfolial iffeet§.if ii'eae.i-sirlyTff.•-.:•..':;;. :.4...•'•;..f.:V.:::!:' GeoFROM TO DESCRIPTION Valor,hardness,soil/rack type,grain she,etc.) t thermal(Heating/Cooling Return) Other r10 (explain under#21 Remarks) - _ 0 .ft. -2 4.Date Well(s)Completed: \;1\'2.'3 Well ID# ' "Aft. C ,t. ft' \ \ric\tAf ' d Tft)(.1. 5a.Well Location: 1 ft. ---1ni. rj:1-7tAj 1 yzunnis-L.... .SAKUjelou.k)ill4kg- • ft ft • • . ' FacUity/Owner Name Facility ID#(if applicable) ft ft. 17 .-77.'-'-' :71'::-• .:;;.:-:!:-.''' 11'V g cW'l Lava M6Dreyn\U 1(.vg'11 1 ft ft. i2, ',,..,r;''',-,",S-a '...• 1,--1. Physical Address, ty,and Zip • ft. ff. MAR ,.) (s, ' 0`2_3 • • -:-2.11aR--MARKS''':..fi..1:.;::'''..--.77...•:a.;'`:....:r.i.:',E,•••71::;,. .;',-"-7::.....!.:2!:',':. 1-';.,?.,•'-'::...7.-f r - :,• '',n';;:-.;';',-:::;:.?:::1 :'-.7'.:';'.:,-..:' :'-.:") ,••... . County Parcel Identif cation No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • (if well field,one let/long is sufficient) . ; .Si GlCn .cation: 7.1 0 "N -ACO.V Lrl(P0 W W - . '• • 6.Is(are)the well(s)*Perm ..anent or Temporary Signa.r e IF rtif ed Well Contactor •Date .S/ping•is form,I hereby Celt('that the well(s)was(were)constructed in accordance " 7.Is this a repair to an existing well: 0Yes or *No with 15.4 NA•C 02C.0100 or 114 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 thui 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 I GW-1 is needed. Indicate TOTAL NUMBER Of wells construction details. You may also attach additional pages if necessary. drilled: - i SUBMITTAL INSTRUCTIONS 9.Total well deptb.below land surface: -1 0 0 • gt.) 24a. For All Wells- Submit this form within 30 days of completion of well Form ultiple wells List all depths rdifferent(erample-3@,200'and 2@,100') construction to the following: 10.Static water level below top of casing: Lk-0 (IL) Division of Water Resources,Information Processing Unit, • Ifwater level is above casing?use"+" . 1617 Mall•Service Center,Raleigh,NC 27699-1617 -' 11.Borehole diameter: 6 (in.) 24b.For Injection Well: In addition to sending the form to the address in 24a 12.Well construction method: ro.t-cir(.. . above,also submit one copy of this form within 30 days of completion of well , '(Le.auger,rotary,cable,direct pnsh,etc.) construction to the following: • • • FOR WATER SUPPLY WELLS ONLY: .. 13a.Yield(gpm) . Me 1 \ ,G thod of test: • air pressure 13b.Disinfection type()AlastiN6 Amount: 2%01_ Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 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 completion of well construction to the county health department of the county • where constructed. Form GW-1 North Carolina Department of Environ •mental Quality-Division of Water Resources • Revised 2-22-2016 • . . • • . - -•