GW1-2023-01706_Well Construction - GW1_20230213

aTwonrractoLIE121maqon:
I �
12 14:.WATER ZONES ;
Well Con for =me, FROM TO DESCRIPTION
�4�i ft ft
NC Weft
ll Contractor Cer4cation Number
15:OUTE&USING,(fo`r m *&i MT
nlfi-disea s)OR RR(if IIcahle)'=r
Morgan Well &Pump,Inc. FROM ITo' D1Anti TER THIrEv>ea MATERIAL
Company Name
+1 ft w ft 61/81 m' sdr2l pvc
16:'ERM CASING OB•TUBING. eotIiWnma cl6'sed-ldo
2.Well Construction Permit4: FROM To I DIAMETER I TTLICENns = ~ MATERIAL'
List all applicable well constructionpermits'(ie.WC,CoWgv,State,Variance,etc- ft• ft
3.Well Use(check well use): R ft rn
J
ater Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS ttMATERIAL_
gricultural nMuaicipa]/Public ft. ft
eothermal(Heating/Cooling Supply) NIResidential Water Supply(single) ft in
ndus ommercial Residential Water Supply(shared) -
ftion FROM ODT.TO MATERIAL - Fes••k CEMENTh=011&AMOUNT
ater Supply Well: o ft. 20 ft bentonite poured
Monitoring. ORecovery ft ft
n.We1I
ft M
er Recharge 1�Groundwater Remediation r.
er Storage and R=6d ery S Barrier al,nriv FROM TO � MATERIAT, E.MPLACEMFNT METHODer Test QfStormwater Drainagemental Technology Subsidence Control ft ft
ermal(Closed Loop)rmal(Heating/Cooling Return) i Other(explain under#21 Remarks) OM TO DESCRIPTION(color,hardness,saiVrock typq. ft
4.Date Well(s)Completed: Well ID# ft. ft
5a.Weil Location: ft ft•Nm
ft it.
Facility/ a Name �\ Facility M#(if applicable) ft ft
_(Atb fW. t ft
Pbysical Address,City,and Zip ft ft C t B I 201Z
-
UrIA
County Parcel Identification No.(PD4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 er ration:
35.S3(00 -N SOAR 191 W2�-
6.Is(are)the well(s) Permanent or OTemporary Signa e f ed Well Contractor Date
B o r ng s form,I hereby certify that the wel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ell or SNo wuh 15.4 C 02C.OI00 or 15A NCAC 02C•.0100 Well Constvcdon Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature offhe copy ofthii record has been provided to the 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 I 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 Iand surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Grt all depths ifdifferent(example-3 r) DD'm:d 1Q100� construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above, also submit one copy of this form within 30 days of completion of well
O L( construction to the following:
(ie.auger,rotary,cable,dsectpusb,etc.)
EWATUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,RaIeigh,NC 27699-163 6
Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fomm within 30 days of
typ Amount: `�n-L completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016