GW1--03025_Well Construction - GW1_20230306

I.Well Contractor Information--
(�C�e I:T I QUSe, •14:.W_TER ZONES:'.
OM TO DESCRIPTION
Well Contractor Name p ft /� ft
ft. ft.
NC Well Contractor Certification Number
� '15;OTUT�'ER:(�G,(fn"r mnl&=rased vrelLs)ORISI�?t C:f'a-'licahIe)'v ::'.:.::••`
Morgan Well&Pump, Inc. FROM TO; DTAMF'f'RR TmL IFss MATEMLLL
+1 ft, 61161 m' sd2'I pvc
Company Name
_2.Well Construction Per 11�� 16"Il�TiI)sR CASII�TG OR•'TQBIl1*G:'eotTier'ma7 elo'sed-lob' ?.i::;��.•_. '•-�•'•.•.;...�..
mit#: FROM To DIAME= TfficxivEss MAT>�AL
List all applicable well constucdonpermrits' a UIC,Conant,Stale,Tarimnce,eta)• fr' ft �'
3.Well Use(check well use): fr' ft. m.
Water Supply WeIl: 1147 SCREEN', ..:-:::::- .` _•:•.::::;'r::.• ;:: .t_-'J.: ::•.:.::::
FROM I TO I nVJ& Sp, I SLOT SIZE THICKNESS MATERIAL.
I Agricultural E]MunicipdTablic ft ft in.
Geothermal(Heating/Cooling Supply)' ,Residential Water Supply(single) ft ft in.
I industrial/Commercial Residential Water Supply(shared) :IS:GROUT::•. _ ' .::_-- - - -
VAquif�r
tion FROM TO Ma rFUTer. - RMpJ.4CEMENTMETHOD&AMOUNT
ater Supply Well: 0 ft 20 fc bmianite• poured
toring ORecovety ft ft
n Well:
ft ft
er Recharge 13 Groundwater Remediation
er Storage and Recovery MSalinityBamer %11rIG TO�LPA�MATERIALe •.. •,•J EMPLA.=NTilv=HOD••• -••
er Test UStorrawater Drainage r�imental Technology Subsidence Control ft. fr•
ermal(ClosedLoop) L3Tracer :20.DRff=NGXoG:(attach-addition'sls"eetsifnecess ry*1rmal(Heating/Cooling Retum) i Other(explaia uadert21 arks) FROM To DEscRI ION(color,hardness,soiUrocktype grain svr ate) e /
/ d ft <6 ft r r
4.Date Well(s)Completed: 1 r Well ID# • It 46, 4f,Sa.WellLocation: b D ft a
Facility/Owner Name Facility EDiV Cifapplicable)
3c)z Cf5 ft ft
Physical Address,City,and Zip ft. ft. A O n
C"WP4\, 2?79Z.S67Sq `21:R-�aRu��.::::::=�:�—l:•.._;: ..:.-._:_-__:_;.: _.,-.:-�. ' t�1:::.:.::=:==:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
Cifwell field,one lat/lon9 is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or OTemporary Sienatnre of Certified Well Contractor Date
&v sig ring this farm,I hereby ce:7ify that the wefl(s)was(were)constructed in accordance
7.Is tbis�a repair to an existing wen: ©Yes or° 11 No with 15ANCAC 02C.0100 or lS.4 NCAC 02C,0200 FPeH Comb-uction Standards and that a
IJDds is a rep air•,fnII aut known well consbucfian information and explain Die naiw•a ofthe COPE otitis record has beertprovided to the tsell'owner.
repair under 421 remarla•section or on Die back of Dais form
23.Site diagram or additional well details:
S.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 TOTALNUhdBER-ofwehs construction details. You may also attach additional pages ifnecessary.
drilled. SUBMITTAL INSTRUCTIONS
C
9.Tonal weII depth below land surface: ft) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list nil depths if d fflarent(example-3@200'mid 22
@100) construction to the following:
)
10.Static water Ievel 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
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
% f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6 L` - construction to the following:
Cie.auge,rotary,cable,directpush,eto.) - J
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY V8LU ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 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 type: 1 C rtnv1� Amount: `(6 Oil. completion of well construction to the county health department of the county
z where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of WaterResources Revised 2 22 2016