GW1-2023-00526_Well Construction - GW1_20230109

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1.Well Contractor Information-
FROM
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AQ�'�e�� C�QUSe •14:WATERZONES
FRO T DF_srRIPTION
Well Name
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NC Well Contractor Certification Number if_
1.,15;ODrER:(> r_(Aoc mulazt!isefl wells)0-A MNFR
Morgan Well &Pump, Inc. FROM To' 11011111011
DZ4METER i T� s MATR.RiA7
+1 ft 61/a/ ml sd2l Pvc
Company Name oo A 16.-RIU RCASING0RtTIISIlYe.' ebtheiinalclo'su-166"
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2.Well Construction Permit#: FROM TO DIAII�TER' THIC arcs MATERIAL
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List all applicable well construc6anpa7?d&'(Le.UIC,Cotariy,State,rmiance,etas fi m'
3.Well Use(check well use): ft
i
ater Supply Well: FROM To DIAMEI E&':,SLOT SIZE THICKNESS MATERIAL.
Agricultural 0MunicipaMiblic ,.- ft & m-
Geothezmal(Heating/Cooling Supply)' ResidentialWater-StIIpply`(single)�,,; _y ft ft
lndustdal/CommPmial E3Residentiai Water Supply(shared) :_78:GROVT._.• _' :_=:'.' _ - ;.: :.:.^:.L' -•::_:; ;
E lm ation J AN 0 9 Luu 1 FROM TO rdAaTRTAL J I Lgt NT11�T$OD&AM011NT
Non-Water Supply Well: V 0 ft 20 $ bentnnde• poured
Monitoring Rec0veryn;;sf;,'<05's^;1 ft fL
Injection Well: '"� �• ft ft
_Aquifer Recharge �GroundwaterRemediation
:.79:SAND/ A na"ficabre -`•
DSalinlyBanier EIS PLACMF'N:TAgnirStorageandRecovery GV ,I�THiO D
Aquifer Test QIStormwaterDniinage D
i Experimental Technology ©j Bubsidence Control ft
Geothermal(Closed Loop) �ITracer :20,DRILLINGS OG'{ktaiF dd1fionaT s7�eetsjfaeeess'
I Geothermal(Heating/Coolinglletum) �Other(explainnnderr 21 ) FROM To
DESCRIPT1oN eoIDr,hardnes sn llrocktYPe n )
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4.Date Well(s)Completed: tL Well TD# s!ft xL
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.52.Well Location: o 9-6 '
GCL �b ft 6 ft
#0,r(yc - 44o oe, ft
Facility/OwnerName Facility ID#(ifapplicable) ft
Physical Address,City,,and Zip
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CA le ft
�. A y�/�/r
County P No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:C �Ila is sufficient 22.Certifi3tion:
S 199 I ,17 W 'Dee �a qV
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6.Is(are)the well(s) Permanent or EJTmp.rry Signature of Certified Well Contractor Date
.Z v signing this form,I hereby.certify drat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ayes or° 11 No wish ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Fen Cansbuction Standards and that a
If drir is a repair,fill our/mown well construction biformation and explain the nature of Me copy oflhis record has been provided to the well owner.
repair under*21 remar/o•section or on the bark of Ais 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
contraction,only 1 GW-1 is needed. Indicate TOTAL NUMBER•of wells construction details. You may also attacli additional pages ifnecessary.
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft.) 24a.For All Wi�; Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(=anple-3 a 00'and 2 00) construction to the following.
10.Static water level below top of casing: (fh) Division of Water Resources,Information Processing Unit,
•Ifwaterlevel is above casino use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
Il.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the foun to the address in 24a
above,also submit one copy of this formwithin 30 days of completion of well
12.Well construction method: 1T0� (r` constmction to the following:
(i.a euge,rotary,cable,directpush,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,,Raleigh,NC 276991636
132.Yield(gpm) Method of test alr pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one icopy of this form within 30 days of
13b.Disinfection type- C qAy of Amouat completion of well construction to the civnty health department of the county
where constructed.
Revised2 22 2016
Form GW-I North Carolina Department ofEnvironmental Quality-Division of WaterResources '
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