GW1--07627_Well Construction - GW1_20231204

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• WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •• i
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FROM TO DESCRBTIONI I
Well Contractor Name ;IA ft, st\ ft I I
4550-A ft ft
NC Well Contractor CertificalionNumber 015w.©F) 0E0ASIIGr(for-nitiz'rl reOlisKOii?II'3�IZT(ifrs 71c11'1e L"'.!1: %. •
Morgan Well &Pump, INC FROM ft. TO•" ft DIAMETER m± THICKNESS MATERIAL
(� /� ` )6. 5 a g t iSion\ PVC
Company Name �'I_ _1 I L�W2�r�01I / w eotlirra aa-,'`c7ose uo 'x-' .,,-�: gfirf4 c;'r7•l-
uV J .�6:.IiVi�Z�G-' Cr'OR'i�[f$.111T�':CR P')`S_rF...k+sia3,�.- �:.:�.k_
2.Well Construction Permit#: FROM TO DIAMETER TH[CRI ESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft en.
3.Well Use(check well use): ft ft 1 �•
ohs.'3 .•Ay 3"r r`;:. ..._,-+ .;;, wn;•r.u�.,.ti '�.
Water Supply Weil: ='���:S.CItF.EL�F;v:�.,•r�e s -a,,.�.=s, •.. i�•iGw � �e. s�,. •_�: ��- �:-'
Pp Y FROM TO DIAMETER SLOT Sr7F THICKNESS Y MATERIAL
L Agricultural DJ Municipal/Public ft. ft �•
_i Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
i I Industrial/Commercial nResidential Water supply(shared) •r ,r,-,?. i W ,;`r y _.� -Y,4 r;•�f•;13°;3 s ta,
$ G O.
Irrigation _FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ® -ft rip ft (� `, i,k_ PV"re
Monitoring DRecovery ft ft•
Injection Well: ft ft '
*Aquifer Recharge 10 Groundwater Remediation s .- ate Yti
?Il;iS41VD/GR(ai 11 ffbleW s` :�M-VRa�i _`"
UTAquifer Storage and Recovery ©ISa1inityBasipr FROM TO MATERIAL EMPLACEMENT METHOD
MiAquifer Test DStormwater Drainage ft ft
:11 Experimental Technology ©II Subsidence Control ft. ft. ''
r_.i Geothermal(Closed Loop) OTracer ( :: . S'1` 2 `�"-`' tillrr . ei
O�DRILt�`IGOCx alto. sfi4nal`s7reetafnece`a
FROM TO DESCRIPTION(color,hardness,soillxnektype,grain size,etc.)
11 Geothermal(Heating/Cooling Return) �Ii Other(explain under#21 Remarks) ft. /6 ft rte....)
t�J `�`
r rY _t._.P ti. .,: Li n"- ,�
4.Date Well(s)Completed: 11'1r G�^23 Well ID# �Oft �3 f• fJ fo*#^, 0:rr
5a.Well Location: ' Oft cc) ft. �`6`�F ( t� ()L/. i i 2023
AiVa.('o cru1,-6(JZwG r '+p,0 f. lk ft 4!vc_79 rt - s 1-4,13-rt-, . .:;1 :'. .`• z:�.J l_N,,
Facility/Owner Name Facility ID#(if applicable) voft t j ft �in& :4 G':':e:, '�'.s
' Q 3 �13 S((i eas Coo w rU ft '� ft.• F
' Physical Addd
Ci ress,City,and Zip ft ft I 4i 4 4(6-?5 r)21x13E11A' Illk-, :-_._. f' f'.:0:1•'a''erz"Ysigrnas v. ,l•lrAZ54...£ .t.1-
County ParcelIdentificationNo.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification:
3S-i06G N gO, ef cg. • W f AblicAS,J 2 2c35
• 6.Is(are)the well(s) Permanent or 0Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or rXNo with 15A NCAC 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 of this 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 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: �‹1 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q 00'an
W 00) t cons ruction to the following:
I
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 27 69 9-1 617 .
11.Borehole diameter: (in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(i.e.auger,rotary,cable;direct push,etc.) 1I •
Division of Water Resources,Undez'ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: " 1636 Mail Service Center,Raleigh,NC 27699-1636
-
13a.Yield(gpm) ' Method of test:• // p f 'i ( i'-- 24c.For Water Supply&Injection Wells: In addition to sending the form to
/�'j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: '1rr'ain Ii
'(es. Amount: / 0 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