GW1--04883_Well Construction - GW1_20230728

• . YY.tjL U.01NLL.1Ji Uc.;1uU1N RECORD(GW-1) PorInternalUse Only:. •
1.W onfractorinf -motion:
v, ry .
•14:.WA1'_t51tZONES;•. -...-.-. - . .:.-
Well Con for are • ' • FROM TO DESCRIPTION
r ft ft_
�cI_ r t ft, f.
NC Well Contractor Certification Number '15;O u:xieit,(ASING,(iuc mnlfi ea wells)b12IdIgF.(Talilicable)' :::::•:::::*-:•.
Morgan Well&Pump, Inc. - FROM TO' DIAMETER • TBICItr`IESS MATERIM,
Company Name •
+1 ft• .3 b ft• a 1/8/ in' sdr11 pvc•
16:1NNERCAEING012:•luBING:.W6tlermaI•dosed-loop)!;:.:'='-_• :•6''-
2.Well Construction Permit#: 1 COCA 2�J4Sn FROM TO DIAMETER T carrasS MATERIAL* .
List all applicable well consbuctionpennits'(i.e.UIC,County,State,Variance,eta)• ft. ft• m• •
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17_"SCREI T',>>:: :. .'�: =.`_ ::'e::.•s ;..:-`.;:-l• :; : .:::
• FROM TO DIAMETER SLOT SIZE TATCIOVESS MATERIAL.
Agricultural DMnnicipal/Public • ft ft_ in.
!Geothermal(Heating/Cooling Supply) �1'i Residential Water Supply(single) ft • . ft in. ' •
IndusiriaUCommercial Residential Water Supply(shared) • _
Irrigation FROM TO MATERIAL. E1s7PL_4.CEMENTMETHOD&AMOIINT
Non-Water Supply Well: • o ft• 20 ft• bentonite• poured
Monitoring nRecovery • ft ft.
_Injection.Well: - .
ft ft.
Aquifer Recharge 0Groundwater Remediation
:.79:SAND/GRAVEL-PACK(ifapplicable)'-:,,;::?o:= _•..'-i�•t'_.'•::•',•'..�
Aquifer Storage and Recovery DSslinityBarrier FROM TO • MATERIAL - EMPLACEMENT METHOD
Aquifer Test DI Stormwater Drainage ft• ft.
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) DTracer . , ;20.DRILLNGSOG'(attacfaddition'sliffeetsaiaece,Fsar lti�:•t=..,
•1 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi]/rock type groin size,eye)
r r ®® C . `6 ft 1J't+'Vro Itrt
4.DateWell(s)Completed:Lf jail `a"� Well RV { a. ft. •t ft• x�� GIB _ .
5a.Well Location: _AO ft.
r (1. ft.
�ktfC 66 Lit• •
( t'� .• ft ft _
� .:•
�:® �
Facility/Owner Name Facility ID#(if applicable) ft ft „..,-,
Sib`k FrtuAlJe i iik.)L Z404c ft it JUL 2 8 209'
Physical Address,City,and Zip •
Maktel^-61)V% I en.
‘'1k2-,"C" .21. tmaRys - • ..._.- ._Talr6 v'Fiii'ki3?} 'ti}xW. ."-i.Li'el
Dtil S"
County ParcelldentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • .
(if well field,one 1at/long is sufficient) •
1 i 2 cation:
35.a'� N �
�� • � . 1 �S' W le3C1/°15
Sign6.Is(are)the well(s) Permanent or 0Temporary Sig e i rtified Well Contactor
B going is form,I hereby cerh,fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fy Yes or •No with 154 N C 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 ofthii 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 land surface: I (f) 24a. For All Wells: Submit this folio within 30 day) of completion of well
For multiple wells list all depths(([diferent(example-3 ,200'and 2@100') construction to the following:
10.Static water level below top of casing: 445 (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
g above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 0• l Liconstruction to the following:
(Le.auger,rotary,cable,directpusb,etc.) • • •
' Division of Water Resources,Underground Injection Control Program, .
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a._Yield(gpm) I • Method of test air pressure 24c.For Water Supply&Infection 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 a`N,ee . Amount: 2e3 err--
rr 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 22 2016