GW1-2023-00443_Well Construction - GW1_20230109

1.Well-Contr torinfcrmatio
V� •14.. A.TERZONM:.'
Well ContractorYTaloe FROM TO I •DESCRIPTION
2. 1^ . ft f, i
'!J- ft ft
NC Well Contractor Certification Number
15:OUTER-CASING,(iocmulti-da$eiivrells)QRLIliEktCtf licahle'J:::::.::'
Morgan Well&Pump, Inc. FROM I To. I DIAMETER THICIfivEss MATERIAL
Company Name +1 ft ft 611D1 1 �' sd2 c
1 pv
16.`Dum CAgNU OR•TUBING:'•eotl(ekit z cl6'sedaod".
2.Well Construction Permit zo?_ — `' , FROM TO DTRRTP:R TA I TMCKNESS .. MATERIAL
' #. �
List all applicable well construction permits'(Le.WC,Cow*,State VwZice— _eta)• ft ft. In
�3.Well Use(check well use): ft ft in.
Water Supply Well: 17"SCItEElv',:,:: - .t: <'•_•.`_ - r`:. .(:' ::�.y::i:.'r:;.:. .::.;
FROM TO DIAMETER• SLOT SIZE .Trrrcmms MATERIAL
Agricultural -ilMunicipal/Public ft ft in.,
Geothermal(Heating/Cooling Supply) #Residential Water Supply(single) ft ft �•
I Indus Commercial I Residential Water Supply(shared) ;,Y8:GROUT::.
hri ation FROM TO I MATERIAL E1R7PL.4CEMENfMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt bentonite• poured
Monitoring 13Recovery ft ft
Injection Well:
Aquifer Recharge Groundwater Remediation
ft ft
:.79:SgIID/GRAYEL'PACKtfa'lira6l .:;. . _''::'. •.:'.'i`•':.'•:: ":. :•'
Aquifer Storage and Recovery OSalinity Bawer FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 11StormwaterDrainage ft ft
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) DTracer :2D.DRIILINGLOG'(aftacli sddilirinal sheetsifaecess"7' =.
I Geothermal(Heating/Cooling Retum) I Other(explain under#21 Remarks) FROM To ft DESCRIPTION(cot,hardness,soil/rocktype,grain sax,etr-)
i 0 ft
4.Date WeII(s)Completed:.I t'llwaii
�1 ID# ft 3,ti ft
� .
5a�Well Location: ft IN U'S ft
ft ftJ J J - T
Facility/Owner Name
Facility ID#(ifapplicable) ft ft
Ph -cal Address,City,and Zip ZC.IS ft ft I v
O� '?1i127tMbRKR�` — �:i- _ .•`r_•':.,/.r".�'.--_,—•i;.:'.,..i•C;:::�>- yy
•lllfL,iY:G,i i�t .`r�r�l::'y..�:^^�i tl irl
County Parcel Identification No.(PK
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(3fwe0 field,one lat/long is sufficient) 22• ertifiration-
�T N o , (��� W -�
6.Is(are)the wells) Permnnent or E]Temporary Siena N -ed Well Contractor Date
By gn rag t u form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an eldsting well: UJ Yes or &No wtl A NCAC 02C_0100 or ISA NCAC 02C:0200 Mell Construction Standmds and that a
Ifdils is a repair f out known well construction information and esplain the nature ofthe copy ofthis record has been provided to the msell 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 d4.ys of completion of well
For multiple wells list all depths ifdifjerent(example-3Q200'and 2Qa 100D
1 •�`� construction to the following:
10.Static water level below top of casing:_ to V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casrna use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection WeIls: Th additionl'to sending the form to,the address in 24a
12.Well construction method: r L� above, also submit one copy of this fbim within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,duectpush,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS,0NLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuuDly&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 d _ Amount: completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 2 22 2016