GW1-2023-01708_Well Construction - GW1_20230213

1.W 'ontractor motion:
_ 14:.WA.TER ZONES
Well fiontraq&ame FROM TO DESCRIPTION
ft ft
r
NC Well Contractor Ceri4cation Number
IS:OUTER�ASING,(focmniti 0seawins)0 2LII�I2 tf
Morgan Well &Pump;Inc. = FROM TO' DTdMTM QR THICK�Fss MATEWAL
Company Name +1 ft- $ ft 61/81 i sdt21 pvc
•/1,�1� 16.`1t� M CASING OR TUBING 'eothefinal o'sed-log"?.':."=•e• <'.:s' . .
2.WeIl Construction Permit#: LV�+— FROM TO DIAMETER I THICKNESS I MATERIAL'
List all applicable weA construction permas'(Le.UIC;CowntK,State,Variance,etc.). R. ft in.
3.Well Use(check well use): ft f in-
17-SCREEN.
Water Supply WeII: FROM TO DLIMETER SLOT SIZE YTHrcKNms �MATmmL
_'.Agricultural Qi Muaicipal/Public ft. ft in.
Geothermal(Heatiag/Cooling Supply) JOResidentiad Water Supply(single) ft
I IndushiaU omnmercial _i Residential Water Supply(shared) 18:GROUT:[Aq-
In
non FROM TO MATERIAL EMP CEMENT hl=OD&AMOUNTater Supply Well: o ft 20 fL bentonte poured
toring ORecavery ft ftn.Well: ft fter RechargeGroundwater Remediationer Storage and Recdgery nSalinityBarder FROM TO MATERIAL EMPLACEMENT METHOD
r Test StormwaterDmainage ft ftmental Technology Subsidence Control ft ft
rmal(Closed Loop) TracerRU=G.LOG'(ittticliadditiomiilslieefsifiiecess FROM TO DESCRIPTION(mlarhardness,soiV,.ck ty e size,etcrmal(Iieating/Coolin1g`Return) J Other(explain under#21 Remarks) 8 it a 5 u�Yl��b SCE'
4.Date Well(s)Completed: l\ 2 Well 1D# �j. R t, o ft
Sa.Well Location: ft. �() f
ft
Facility/Owner Name Facility ID#(ifapplicable) R ft. -Figr{
3°155 n(c.Na+A.JL15`zW C�.,�a, ('-,,�,,� Nc 2 ft. ft
P ical Address,City,and Zip ft. ft i-S,_, f =_.i=- J 1:r.1
tv
Zlc'RFM6RKS" -i.'
County ParcelIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(>fwell field,one lat/Inng is sufficient)
2 er cation:Ili
35.5(0�1� N �b.��g47 W �i Dq f
6.Is(are)the well(s)*Permanent or E3Tempor2ry Signs Lfrldrtifed Well Contractor (`
B fining iv form,I hereby certify that the wdl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or WNo wuh 15A C 02C.0100 or 15A NCAC 02C•-0100 FFeA Construction Sranda dr and that a
If this is a repair,fill out keo wn we-B construcSon information and explain the natw•e of the copy of ihii record has been provided to the vmll awner.
repair under#21 remarks section or on the back of this form
23.Site diagram of-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 Iand surface; vo (ft) 24a. For All WeIls: Submit this form within 30 days of completion of well
For multiple wells list all depths irdierent(example-33@200'and 2@100) construction to the following.
10.Static water level below top of casing: v D A) Division of Water Resources,Information Processing Unit,
Ifwater 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 form to the address in 24a
~ 11 Well construction method- �� LL above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
EDWisinfection
SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
0 Method of test: all pressure 24c.For Water SunDly&Iniection Wells: In addition to sending the form to
Q the address(es) 'above, also submit one copy of this form within 30 days of
th
typ Amount: \ �Z completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016