GW1-2023-00517_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.'Well Contractor 7nfz-mation_
ACC'CG Clause e •1A::47ATERZONES�,', •.I� ,�i..•:.`
_
OM I TO •DESCRIPTION,
well Contactor Name % �PrA ft
NC well Contractor Certification Numbef I5:ODDER-•G�6�SIi�'G,(to"r multi ragea w Rs)0P-1Mq R Cir - �)' ='::'•:•:-':"`
Morgan Well &Pump, Inc. : FROM TO' DIAMETERi Tzrclagms MAT.�uL
/f +1 9g 6 119/ m sdfLi PVC
Company Name C/�� ��L�� r "::_• :_:'::• ;
` x5 IIT�TEdt CASIATG OI2•TQBIPIG: eatliecmal cIo'sed Iflfi
2.Well Construction Permit#:
FROM x'0 DTdMF'rTsR; THICE2ms MATERIAL
List all applicable weII construction permits(e UIC,Corm State Ymfmrce etaJ. ft
3.Well Use(check wen use): ft ft
i1ndustrial/Commarcial
ater Supply Well: 12 SCRF�LN'.=:: - .`: '• :=:::. .;::,;-:•:::,. - •.::
�;{ FROM TO DIAMETER~ SLOT SIZE `TffiCKitESS tvIATAT ERTA7..
Agricultural 014unicipdTublic in ft in.
Geothermal(Heating/Cooling Supply)- Residential Water Supply(&gle) ft ft E3Residenfial Water Supply(shared) :i8:GROUT:bi ,, _" -•::':''M''' '%; :.;='::-�r `.:
lid on FROM I TO ,16ATF'RIAL - JER7PL4CEMENTMETI�OD'&AMOUNT
Non-Water Supply Well: o ft 20 ft bentan'ite• Poured
Monitoring 13Recove-y ft ft
Injection Well:
R ft
J Aquifer Recharge KI GroundwaterRemediation
:.19:SAND/GRAYEL•PACg ti a`liekb :.::.='.::':.:•_'=: . .:', :•: t
Agnifea:Storage and Recovery nSalinityBanter FROM TO MATMUAL EI14PL.CEMENTje=OD
Agtrifer Test 13Stommiwater Drdnage ft
i E,9perimnental Technology ©li Subsidence Control ft ft•
Geothermal(Closed Loop) OTracet :2D.�RILLU3GS OG'(aftacliadditiaz s eets neces'-7 t=s .`='•:' 'ii�:
t Geothermal(Heaiing/Cooling Retain) Other(explainunder-01 ) FROM DESCRIPTION(wlo,hardnes sail/rock type,grain Sim eto)
.� p ft a fc .*( —
4.Date Well(s)Completed: 2' C a 2L Well ID# • ft' ft. fv441 v'm'i
Sa. Location: O D ft.
'/ ft
Facmai'ty/Owner Name Facility M4(if applicable) ft fL
Z136' ��r►n� 6j(\— .s ue,. -
tz ft
Physical Address,City,and Zip
L/'�L6 �� r7�Z l.i� °21i721'i.MdRKR=- <t.:- `�r' p:•.'_ - _ .'� — i
County Parc ldentificationNo.(PIN). A�
5b:Latitude and longitude in deggrees/minutes/seconds or decimal degrees:
(if ll fiel one laUlo is sufficient ;i 1
C d n ) 22,Certification: D\.l1 ,, G
7K ���Z N ��. 121 C/� w ��e�ti ' 2o-a
6.Is(are)the well(s) Permaner or OTemporary Signature of Certified well Contractor, Date
by sio ma this form,I hereby certify that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or' No with 15ANC,4C 020.0100 or 15.4 NCAC 02C,0200 WeII Constnrction Standards and that a
If fhis fs a repair,fJV oaf taro wn weR construct on information and explain the nature ofAe copy oftW 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 additions]well site details or well
construction details. You may also attach additional pages ifnecess any.
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBERbfwells'
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth,below land surface: (in) 24a For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ff dif�ere»t(irmnple-3 a(�l 00'and 2 /OD) construction to the following
10_Static water level beIow top of casing: (ft) Division of Water Resources,Information Processimig Unit
•Tfwoter level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in) 24b.For Infection Wells: In addition to sending the foram to the address in 24a
I above, also submit one copy of this fomm within 30 days of completion of well
12.Well construction method: QLALI construction to the following.
(r_e.auger,rotary,cable,dsectpvsb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,,Raleigh,NC 276991636
' - I
13a Yield(gpm) Method of test air pressure 24c.For Water SuuDiy&Iniection Wellsi In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection ty �pe:.=C 01 ds- Amount.• 7102- completion of well construction to the county health deparhnant of the county
where constructed.
' I
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22 2016