GW1-2023-00441_Well Construction - GW1_20230109

1.Viell Contractor Information: 0J
•14:. ATERZOIVES-.'. .-
Wel n44jrNanir FROM I TO DESCRIPTION r
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NC Well Contractor Certification Number
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OUTER:CdSING,(fo"r tiinlii=rasedvreDs)ORT2�(ilia'ucable)'s:�::'.�::'•
Morgan Well&Pump, Inc. : TO' DIANETER i TBICM E6S MATERIeu
Company Name ff fi 6118! iu' sd27 pvc
� �� � _ � FdINB�R 012•TCTBING"eotTier�aZcla'sedloo :_ r
2.Well Construction Permit#. FROM TO DIAMETER f TfficlQtPss MATEaL9L
List all hcable well construction ermits Le LUC,County,State,Yariance,etc• m'
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3.Well Use(check.well use): ft !L i m.
Water Supply Well: MFROMTO
MIA�� .
DIAMETER SLOT SIZE TffiCICVFss Agricultural MMunicipal/Public in•
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) in.
stn Commercial J Residential WaterSuppIy(shared)I Irri ation MATERIAL EMPL4CRMENTMETHO
Non-Water Supply Well: o ft 20 ft bentonite• poured
Monitoring DRecovery ft ft
Injection Well:
. ft ft
_!Aquifer Recharge Groundwater Remediation
- ;.-19:SAMIGRAVFS'PACK Cf a'lirali]e ':.:;.•'`;:?: +
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT iv=OD
Aquifer Test QlStomiwater Drainage' ft ft
l Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer :20.'DRMLINGSOG'(attachadditionaIslieefaifaecess
c I Geothermal(Heating/Cooling Retum) rilOther(explain under#21 Remarks) FROM I TO ft. DESCRIPTION(color,hardness,soil/rocktype,grain s'ae,etc.)
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4.Date Well(s)Completed: ?I ell 1D¢# 1 n ti'
Sa Well Location: �
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Fatality/Owner N�ama �adlity ID#(if applicable) R ft.
�sicalAddresss,,C/itty,an ip ft I Q Q �`'��
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sufficient) 22_ cation-
6.Is(are)the well(ANPermanent or [ Temporary Si, ertified Well Contractor it Date
By s form,1 hereby certify Shar,dh�e well(s)was(were)constructed in accordance
7.is this a repair to an e7dstmg wkl: fl Yes or RINo w' lSANCAC 020.0100 ar 15.4 NCAC 02C•.0100 Well Construction Standards and that a
Iftlds is a repair,fn11 out known we11 construction Wormation and explain the nature ofthe copy ofihis record has been provided to the well owner.
repair under W21 remarks section or on the back of ibis form. i
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells baviag 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 ifnecessary.
_ drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ©� (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3@,200'and 1Q100D construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources;Information Processing Unit,
gwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 m.
(• ) 24b.For Infection Wells: 1n addition to sending the form to the address in 24.
9 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �` construction to the following:
(r.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPP iLY WELLSIONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 1 Method of test: air pressure 24c.For Water Supply&Iniection 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 Amount: completion of Well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparment of Environmental.Quality-Division of Water Resources Revised 2 22 2016