GW1-2023-02499_Well Construction - GW1_20230406

YYi.,�1-11,UUIN 1_CUC11UN RECORD-(GW-1) For Internal Use Only.. I ; • .
1.W contractor Inf ration: • , ,
i 1
14:.WA17a'RZONES : :•:: _
Well Co for are _ FROM TO _DESCRIPTION
f. ft.
- 4/� ,.r s C ` ft ft. I
I '
NC Well Contractor Certification Number. :
., • •15:O u,.tat.GASENG,(fac mnlfi=rased wells)(7R ling(ifap licahle)'=1::::'.:• .-
Morgan Well &Pump, Inc. : FROM TO' DIAMETER I THICKNNESS MATERIAL
• ' +1 ft. ft 61/8/ m' sdi21 pvc
Company Name
3 O� I6.`INNERC' OR.1'ui G.(geotlierma1alo'sed-Iodp)L:`:.:`-'•_' :; '•':.:'•••-
2.Well Construction Permit 4: i 11 FROM TO DIAMETER THICKNESS MATERIAL'
List all applirthle well constuctionpermits•(xe.UIC,Counts,State,Variance,etc)• ft. ft. . in. •
3.Well Use(check well use): ft ft' m
•
Water Supply Well . 17:SCREE.'N`.:,:.:;.'`:... .'":;'•-1.:: :. -t7:. -S`,.n:,-.`f.•-.it•",,:;•.:.•.:=,' ..
�{ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
*Agricultural DMunicipal/Public . • ft ft in.
Geothermal(Heating/Cooling Supply) MiResidential Water Supply(single) ft • . ft in.
STndustrial/Commercial LaResidential Water Supply(shared) ::1s:GROUT•:,.••:: = r•`'"''•' - "'y•• '
:ligation FROM TO MATERIAL EMPL-4CEMENTMETHOD&AMOUNT .
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring DRecovery • ft. ft. -
Injection.Well. -
ft. ft. • .
Aquifer Recharge El Groundwater Remediation :.79:SAND/GRAVEL•PACK(if applicable)•':•:7.,•:;;.' _.':. .'`-•: •._• `-
Aquifer Storage and Recovery 0 Salinity Bather FROM TO • MATERIAL • EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft. '
Experimental Technology (Subsidence Control ft ft.
Geothermal(Closed Loop) 0Tracer . • :20.DRILLIIQGZOG'(attacli additiiival t1i etsafh'hEeikir)i/^::•=s . :
r. 20 va_`A 1
I Geothermal(Heating/Cooling Rearm) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
t ft ft tr C
4.Date Well(s)Completed:J,29 Well ED# 20 ft. '•3S ft rov" (.° - .
5a Well Location: 35 ft So ft. h
Sa ft- Loa ft w
NYor Y�-
+ k .
Facility/ wner Name Facility ID#(if applicable) Go ft 42.c Co<rt��
4 o NrcIA.CAMI C1 .5a&4 y NlC2g N4 ft. ft � .. �. .
Ph sisal Address,City,and Zipft ft
County Parcel Identification No.(PIN) APR\ 0 6 2023 .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cif well field,one lat/longissufficient) 2 %J �irilG ia-; ;:C1l rC?iL✓4Flg Ur
I � .ration:/6�
'N ���l •4j1 v.a a t'S..:L,
'� 0 3
6.Is(are)the well(s)*Permanent or Di Temporary Signa.air :.ed Well Contractor -D e
B aligning-is form,I hereby cernfy that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well.: QYes or s,No with 15AN.t.-C 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a •
If this is a repair,r,fill out/mown well construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under 421 t•emar/s 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: . - I SUBMITTAL INSTRUCTIONS
•
9.Total well depth below Iand surface: 42-C (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3 ,200'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 casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 (in.) 24b.For Infection Well's- In addition to sending the form to the address in 24a
-" lr•r f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0. t �{ J 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 27699-1636
I3a.Yield(gpm)_ Method of test: air pressure
13b.Disinfection ,i( Ii 24c.For Water Supply&Injection Wells: In addition to sending the form to
n�I � � Amount: �� 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 Environmental Quality-Division of Water Resources . 1 Revised 2 22 2016