GW1-2023-01421_Well Construction - GW1_20230208

WMIJ, i-i UUINLIJt if,UULIUIN 1Ck+'C;UKU (CUW-I) I For Intemal Use Only:
1. iractor�ation: ,, I
i
•14:. ATER ZONES-:'. ;
Well Contracto• e FROM TO DESCRIPTION
-`.A ft ft.
NC Well Contractor Certification Number
I '15:OUTER:G�ASING',(foc multi-rased wells)ORTTNF.R Ctf a'lirahle)' :�::'.:.::'•.`.:
Morgan Well &Pump, Inc. FROM TO I DIAMETER' THICKNESS MATFZtIAI
Company Name +1 ft 851 ft 6 1/8/ 1 in' sdf11 pvc
1 1 A ` - 16.`INNER CiiSING OR•TIIBIlTG.' eothermal cIo'sed
2.Well Construction Permit#: L-��e�/{_ �� �� FROM TO DIAMETERS THICIOWS MATERIAL
List all applicable well consttuctionpermits'r e.UIC,County,State,Ymiance,etc.)• ft ft j 'm.
3.Well Use(check well use): ft ft
Water Supply Well: . 17,-SCRREN'_.—. .:::i:; •'�; _•`_:' :.:'r:. __ ,.: -``: .• :..:=`•
FROM TO DIAMETER' SLOTSIZE .THICKNESS MATERIAL.
Agricultural rjlMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft
I Tndusu�Commercial J Residential Water Supply(shared)
r18iGROUT. -:`A
rNo:n-Water
ation FROM TO MATERIAL - EMPL4CEMENTh1ETHOD&.AMOUNT
Supply WeII: o ft zo ft• bentonite• poured
toring CIRe.overy ft. ft_
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
SAND/GRAVEL'PACK mf a'•livable ,
Aquifer Storage and Recovery MSalinity Barrier FRoM TO MATERIAL EMPLACEMENT METHOD
_'Aquifer Test Q1Stormwater Drainage ft ft
i Experimental Technology OSubsidence Control ft ft
I Geothermal.(Closed Loop) [3Tracer :z0.DRIGL7ATG.L'0G7(aitacli`adtiition'al sheed.if
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
' ` ( .�.�
4.Date Well(s)Completed:V-1 1 Well 1D# 5 , ft �`+rJ ft v
52.WellLoratio �.5 ft 2®('eft• ij�
ft ft �s b d,�; ..
Facrlity/Owner Name Facility ID#(if applicable) ft. f• — 1� 0 O a n ft ft `t
l l ( {,^
Physical Address,City,and Zip
ww ft ft )f1SuiAEi3A_l �ii.:?rC•^?�� i Ir;l
Copt. ruu
County Parcel Identification No.O N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laat long is sufficient) 22.C on:
35.`33V>r,
ZIbZ7i
6.Is(are)the well(s)&Permanent or OTemporary Signature a ed Well Cc ractor Date
By si mi g is 1 hereby cettrfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or *No with 15 A 02 .0100 or 15A NCAC 010.0200 Mell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy o s rec rd as been provided to rhe'well owner.
repair under 421 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 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:_ ' I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IN (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3Q20/I0''and 2@100) construction to the following:
10.Static water level below top of casing: V (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the fonn to the address in 24a
above,also submit one copy of this forth within 30 days of completion of well
12.Well construction method: f-0"�( i
(Le.auger,rotary,cable,direct push construction to the following:,etc.) f •I •,
LF0)RATER SUPPLY WELLS,ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
eld(gpm) \ Method oftest: airpressure 24c.For Water Suunly&Iniection Wells: In addition to sending the form to
the addresses) 'above, also submit one'copy of this form within 30 days of
infection type: Amount: completion of well construction to the county health department of the county
where constructed-
Form GW-1 Nortb Carolina Department ofEnviroamental Quality-Division of Water Resources Revised 2 22 2016
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