GW1-2023-00573_Well Construction - GW1_20230109

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NC Well Contractor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER if a licable
Morgan Well & Pump, INC FROM I To I DIAMETER THICKNESS MATERIAL
Company Name ft. ft. tat/8 I in. sd21 pvc
�/I Off•1� 16.INNER CA NG OR TUBING geothermal closed-loop)
2.Well Construction Permit#: a_d 1 FROM I TO DWIETER, THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. i in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in.,
.__Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite; poured
O Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 1ITracer 20.DRILLING LOG(attach additional sheets if necessa )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM f�� ui TO DESCRIPTION(color,hardness sail/rock type,grain size,ate.)
J 1 ] ft ft. _0
4.Date Well(s)Completed: /"� 'Well ID# ft. ft. a r� zr.
Sa.Well Location: ft. ��ft-
Facility/bwn&Parne /�— Facility ID#(if applicable) ft. ft.
�.V 01 (2 /� S 0 ft. ft. _ :t v'ii Gl Z
Physical Address,City,and Zip ft. ft. Ed
a 21.REMARKS I A N 3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: inl3vr +','7°';wSi�
(ifwell field,one lattlong is sufficient) 22.Certific 'on:
•�r��� N �.
6.Is(are)the well(s)oPermanent or Temporary Stgna -of- eitifi3ZTJe11- ontractor a e
By signing this form,I hereby certify thai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes Yes or XX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill out Mown 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 form.
23.Site diagram or additional well gdetails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page fo 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:'
2�^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �f (ft•) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths ifdierent(example-3@200'and 2@100� construction to the following:
f7 �,
10.Static water level below top of casing: c5 � ft.
( ) Division of Water Resources Information Processing Unit
If water level is above casing,use"+" � g ,
6 1/8
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
rotary above, also submit one copy of this'form within 30 days of completion of well
follo
wing:
(Le.auger,rotary,cable,direct push,etc.) construction to the g:
FOR WATER SUPPLY WELLS ONLY Division.of.Water.Resources Under round Injection Control Program,.
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'.�3 Lk 1536 Mail Service Center,Raleigh,NC 27699 1636
f,r gn ettion M d S atv, o❑ tp s alct> ie;..
13a Yield(gprn) J.„ r: Method of!te3It �'r "�'i ?tl- 24c For:3VatCr auDuH- : '&fl ii-8 n i?ti `Ic�trt� *e. i+ e form th 24 x l b.� c..�or 3
the address(es) ab0��e n1so sub ii lone copy of th form iv in-71�r a- of
1-13b,-Disinfection ty e:,chlorine Y
p Araourth j completion of well••construction t0 1(6e�county health,department of the county,;, .....
-where constructed:
Form GW-I Nortli Caroilpa bepart_hicrit of Etivironmental Quality-Division of Water Re&nuces Revised 2-22-2016