GW1-2023-00528_Well Construction - GW1_20230109

1.W oniracfor •oration: L
•14:V7ATER ZO 1.*2,
Well Contractor are FROM TO I DESCRIPTION
2 ft ft f
A ft ft
NC Well Contractor Certification Ntmmbet
15:OVrKP-QASIlV9,(fo"r multi rise3 veils)ORTSITFR.
Morgan Well &Pump;Inc. : FROM o DIAMETER I Tzacm\i Ess MATERIAL
Company Name +1 11' ft 61/8/ sdt21 pvc
16. 2 OR•TI7BING:''eotlierma7.•clo's@d.-lad`l;:."-..;• ::�:`•;`.:. .
,►•fir FROM TO DIAMETER THICKNESS I MATERIAL'
2.Well Construction Permit#:_ �Vl ? ft in
List all applicable well conslrucffon p aunty,State,Vmimzce,etc}
3.Well Use(check well use): ft in
Vdstd.&Commerrial
ply Well: 17."SCREEN:::,: _ .`•�; .:=•_• :::;:. i'� .:..;�,-:`.:-_r,.:r::.:. .::
FROM TO ':_~•DLaME•IZ-Ft SLOT SIZE , T13rCKNFSS ivIATERIAL.-,
al DMunicipal/Public ft ft is
al(Heating/Cooling Supply) N1Residential Water Supply(single) ft : fL in•
I Residential Water Supply(shared) GROUT:;• _ = , - -
fN
tion FROM TO MATERIAL - EMP .CEM.NTMETE011&AM04NT
ater Supply Well: 0 ft 20 ft- bentonite• d
monitoring. Recovery ft ft
n.We1I
�-�{ ft ft
r Recharge 01 GroundwatixRemediation :.19:SAND/GRAVEL•PA:CK if a"-cabre)r Storage and Recdwery n1SalinityBarr FROM TO MATERIAL EMPLACEMENT METHODr TestII(Strmwater Drainage
mental Technology' OSubsidence Control ft ft
rmal(Closed Loop) 1ITracer :ZO.�RILLGLI IGT OG'(attachadditional shermal(Heating/Cooling Return) i Other(explain under FROM To DESCRIPTI N(colorhardnesssaiUrocktypegra nsaeere)
d.f, ��
4.Date Well(s)Completed:e d e1.1ID# it ft-
5 WeIl LocS\ation: f ft. '
Facility/Owner Name 7
' ti Facility
�ID#(ifapplicable) fL ft
ev�"u1 `sit rb n' 1W, ft ti —. -- --
P si Address,City,andZi ft ft
d�/-a ` ZIi-R1iibrARTS':C.er,:' `:r':•.:c; _ _ - �:_ •'`�:n'?;^`'�3�y:
County V r ParcelIdeutiflcation I
No.g9N) - A'` O `9 `-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field lat/lo is sufficient)
,one ) .�/ �.+(l� 2 cafion: , .. �':s.��,.;is•:
v N lJ O FlJ .1�1' W
6.Is(are)the well(s)*Permanent or OTemporary Sigma f rtified Well Contractor Date
Nadng it farm,I hereby cen%ry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or.f Ne 15.4 C 02C.0100 or 15A NCAC 02C..0200 PIeff Construction Standards and that a
Ifth s is a repair fill out known weB constj=don information and explain the nature ofthe copy ofihis record has beenprovided to the well owner.
repair under#21 remarks•section or on the back of thisform 23.Site diagram or additional well details'
8.For Geoprob'e/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. Tadicate TOTAL NTJMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SMMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 00'and 2@I00) construction to the following.
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+' 1617 Mail Service Center,Raleigh,NC 27 699-1 617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition!.to,sendmg the folm to the address in 24a
~12.Well construction method: (r� above,also submit one copy.of this form within 30 days of completion of well
construction to the following:
(Le_auger,rotary,cable,directpush,etc.)
FDisinfection
UPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
• 1636 Mail Service Center,Raleigh,NC 27699-1636
0
Method of test air pressure 24c.For Water SnDDiv&Iniection Wells: In addition to sending the form to
the address(es) 'above,_also submit one dopy of this form within 30 days of
typ Amount: completion of well construction to the lcounty health department•of the county
where constructed 1
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised2-22 2016