GW1-2023-01799_Well Construction - GW1_20230213

l�ontractor •mafion: I . .. :• . ... .. .. ._. .. .. _
.\[�� 14:.W d'itttZONES '
Well Con ame. FROM TO DESCRIPTION
4 InAi ft ft
ft
NC Well Contractor Certif cation Number ` :Is;OU11CR:CASING,(fo"r riurlti cases wells)O p' ) ".
�t LII4FFt(ifs licalrle;s:�::'.:.::.
Morgan Well &Pump,Inc. : FROM TO' DIAMETER THICKNESS MATERIAL
Company Name +1 ft' k5 ft 61/8/ in' sdr21 pvc
35s'3 �� 16INIMR� C• GOR•iul31NG:'(goof!;eirmal•cleSidloup).'.::."'.•�' : •.•-::' •: .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permdts'(r.e UIC,Comity,State,Variance,etc)- ft• ft . in. •
3.Well Use(check well use): ft ft. `rn
Water Supply Well: . 17_-SCREEN',:-:.. _- . -..- .. =?.- . . .:,-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural QMunicipal/Public ft ft in.
0�Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft _ ft in.
•
�P nlzdustrial/Commercial 01Residential Water Supply(shared) 18:GROUT•::. :s _ _ :''''`=•_.;=---- • - - •
t Irrigation FROM TO MATERIAL EMy C TMETEOR&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Xi Monitoring DRecovery ft ft.
_Injection.WPTL• _ _
R ft
*Aquifer Recharge 0 Groundwater Remediation •,.79:SAND/GRAVEL•P.AXIC(if applicable)•- - •.: • -. . .
II Aquifer Storage and Reccl4ery DSalinity Barrier mom TO • MATERIAL • EMPLACEMENT!METHOD '
*Aquifer Test QiStormwater Drainage ft ft
I Experimental Technology rp Subsidence Control ft. ft-
*Geothermal(Closed Loop) oTracer . , :20.DRILLING.LOG•(atticli additional sli"eetsif rieces'sary"7':`:�::•`.-., .'s• '•'
(Heating/Cooling ) natter(explain under#21 Remarks) •
FROM TO DESCRIPTION(color,hardness soil/rock type grain sae etc)
r Geothermal eating Coolin Return
` b ft to ft Yta. atY� •
4.Date Well(s)Completed: 1 `\a\,�Z)-Well 1D# Lb. R- 3n. " bYci1.,6 eivY
5a.Well Location: -
� � `� ft'�a�v+ Ifbc� , >
Iditv1.1 Shn,� n S'S ft. 200 ft _IIt i, e,Yek. t-G•
Facility/Owner Name Facility 1D#(if applicable) ft ft f_ H� 1 'i 2 1')3
�A - �� 1 L
JV Q�\ 1Q� lc y4.( �/1)( ft ft
Ph sical Address,City,and Zip J 1 ft. ft :Ri. ' -'3 •''
\O`l I0l. 22F.MARKC`' ;". r. - ...-..-. ..,...' .-i.. .--. .... -..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/l 2 cation:ong is sufficient) o
35. lode- "N 00.4. Q 1 b ..
6.Is(are)the well(s)Alt Permanent or DTemporary Sigma f rtified Well Contractor .Date
B gning is form,I hereby terrify that the well(s)was(were)constructed in accordance
• 7.Is this a repair to an existing well: DYes or •No with 15A C 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 thii record has been provided to the well owner.
• repair wider#21 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 bf wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9-Total well depth below Iand surface: 1300 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij�erent(example-3Q200'and 2 tQr 100') construction to the following.
10.Static water level below top of casing: 4O (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 form to the address in 24a
~ 12.Well construction method �` above, also submit one copy of thin form within 30 days of completion of well
J construction to the following:
(i.e.auger,rotary,cable,directpush,etc.) .
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `S 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 form within 30 days of
13b.Disinfection typer)(‘ r,14 ' Amount: 132, completion of well construction to the county health department of the county
where const ucted-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2 22 2016