GW1-2023-00568_Well Construction - GW1_20230109

3572-A
NC Well Contractor Certification Number
:.>15'OTiTER'Ci1SIlY•(r.ffor:'molti'-caseil;wells)OTT:T1VER'(if.•a
Morgan Well &Pump, INC FROM TO DIAhIETER 1 THICKNESS X43ERLAL
fl- IL
Company Name l
q ¢:`I6iEINNEI2 t hSTNG;OR::TIIBING 'eStlieririaF'cldse'd466
2.Well Construction Permit#: 3I1 FROM TO DIAbIETER I THICKNESS MATERIAL
List all applicable well ewisimcdon permits(e.UIC, uno-.State, Variance,etc.) IL ft. I
1 iu.
3.Well Use(check well use): ft ft. I in•
Water Supply Well:
::1 SCREEN;:'f:'i:::: :i:',:?.`•i
FROM TO DIphIETER �l SLOT SIZE THICKNESS MATERIAL
:.]Agricultural ;[D=MaVPubl1C ft. ft.Geothermal(Heating/Cooling Supply) al Water Supply(single) ft ft. in.
rndustrial/Commercial __.Residential Water Supply(shared)
'�ii;_'G1LOII •�
MIrrijiation FROM TO MATERIAL EMPLACEMENT A=OD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft' bentanite poured
Monitoring [IRecovery ft. M
Injection Well: ft ft.JAquifer Recharge rlGrotindwater Remediation :....::....:......._....::...:..::.::....
��19;iSAND/GR4ti�'ET�PACK'rEa 'licable':a; •,'::c::::�:::;�::;::;: '•::;r::::��<;::is>:t�::;::::::::::::;;:;;:;
Aquifer Storage and Recovery Salinity Barrier FROM TO M 4TERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ZitD1lIITINGTOG'(attacfiadditioaalsHaefs.iEnee'es y>-t`; :;=<:: >::::::::::
• . .
_ Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,saWroek S in siz ete,)Other(explain under#21 Remarks) ft ® ft.
4.Date Wells)Completed: Well ID# (� fL ft. s'
Sa.Well Location: 3 ft. ! ft. /t e
Imice 4&W s ft ft of
Facility/OwnerrName Facility ID#(if applicable) ft. ft'
2710 S iAl A er fsi. SOi II 56 N ft. ft 1
Physical Address,City,and Zip ft' ft
f�VW�s 1 ::2Y:12 k'.MMRKC::��:i:i:::E::i:':;E::;:•'::�:::�:,:�i:::'t:::`:':::•:�:; 'i��::::�`E:'k::.:c:::::::i:;.::::�vR'i::. ..:.
County Parcel Identification No.(PIN) -„_ nn 'fir "• '^W i ^.t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' tion:
35, CR N "�$o.y49� W
6.I9(are)the well(s) Permanent or Temporary Signatm�e of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ENo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d�5 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ecample-3Qa 200'and 2Qa 100� construction to the following'
10.Static water level below top of casing: 7,S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/S (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) G Method of test: Ir 24c,For Water Supply&Injection Wells: In addition to sending the form to
chlorine the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: Amount: Tot completion of well construction to;the county health deparhnent of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2 22-2016