GW1--03906_Well Construction - GW1_20230609

YYLyLLLU1Va1±CUl:1IUNVFax2URD (GW-•1) For Internal Use Only.. - .
1.W anti-actor I ation: •
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•14:.WA1'LR ZONES c'. ... .. .... •.•_ . .. _
Well Co ”tor ame FROM TO DESCRIPTION
�"!J^— r r ft ft
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r' c ft ft
NC Well Contractor Certification Number
15:OU;LB.R:CA,SING,(for multi=rase3 Wells)OR r:mizgR(ifap licable)'-:,
Morgan Well&Pump, Inc. : FROM TO• DIAMETER THICKNESS MATERIAL
Company Name • +1 ft ca ft 61181 in' sdt21 pvc
�/\ /A�y�� 16 R OR•1'ul3ING(geotliermal.cIided-lode)?.:.;..'•• :•:r•'•••';.:': .
• 2.Well Construction Permit#: V( OW�S FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction pen nits e.WC,County,Stale,Variance,etc). ft. ft. . in. '
3.Well Use(check well use): ft. ft. in.
17.'SCRFLTT'.:r:.: _ • : .-. - •' .yr,.: -.: :
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
DAgticultural jMunicipal/Pubiic • ft ft in.
t JGeothenmal(Heating/Cooling Supply) e liResidential Water Supply(single) ft • - ft in.
�II Tndustrial/Commercial DResideutial Water Supply(shared)
::18:GROUT•:: .. .. _ . :r:'..:.:.•::•:.._-•..:.-... _...•-.... •.
IA
Irrigation . FROM TO MATERL EMPLACEMENTMETHOD'&AMOUNT .
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft, ft.
_Injection.Well: -- -
ft ft.
Aquifer Recharge D Groundwater Remediation
Aquifer Storage '•1:S /��'PACK(ifapplicabre)•-:•:...== •,.'�'-.:'_-:.':'-:'-.
Q g ry •DSalinityBarrier FROM TO • MATERIAL • EMPLACEMENT METHOD _
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 1:3Tracer . , :20.32110:=G.TOG'(atbiElf dditional sheets ifazcessary:t,f ::=s ..
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain s ze etc.)
c ft bg ftcCp,{ 1 r+ .
4.Date Well(s)Completer ) `1 C /7 Well ID# ft ft. 'b
45 fr ' iN'
5a.Well Location: 45 SO n 1 d[
• Facility/Owner Name Facility IDf/(if applicable) ft ft
i . /gi ft j eft n►t
Physical Address,City,and Zip 'C tl�'ft \ VAS'
A•u& illitvt.t.46
.21i-R26RKC'.-.' `.r:. ` „;i4•.
ounty Parcel Identifi cation No.(PIN) r c d.-r L_h , L.,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • I 1 I N �, ` '1 0 L 1
(if well field,one
l1ast/long is sufficient) / •
■cation:
J U GU J
s%, `� 15- -N 30i6i( fr)9, • W 2 - . *n Proc3Nt:15g Or";
' 6.Is(are)the well(s) Permanent or DTemporary Signa.a Irtified Well Contractor • a
B/ruing•is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or s,No wish 154 .k•C 02C.0100 or ISA NC/IC 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 this record has been provided to the well owner.
repair under 421 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: /!145 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd erent(example-3« 00'and 2@I00) 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
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
- Y( ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '-i J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) . • .
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program, .
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
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the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: 1+11 01- 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 . Revised 2 222016