GW1-2023-01800_Well Construction - GW1_20230213

I.W ontractor Inf -mation: •
' I I
•14:.VVATER ZONES-;', . •z.'..-: .: :....• ,...?...:::::',.„.l..':'.......:-.. .7..:: '.:'''.l....':
Well Con tor ame . • FROM TO DESCRIPTION
42Z —A ft.
ft ft
NC Well Contractor Certification Number , .
.'15:0 ETLE12,CASING,(toi tianitir*ea;ivells)OE:LINER(ifari lirbt,.y..-3.:::'.....
• Morgan Well&Pump, Inc. . FROM TO' DIAMETER THICIOTESS MATKRIAL
+1
Company Name . ft.
k 0 ft. 6 1/8/ M. sdr21 pvc
16NKR CASING O
2.Well Construction Permit#: FROM .1.WONG:(Vecitliel-iital.C1CiseclAdiiii)!.f:;."'-.1 is.-;l''':2.....
FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction penniti(i.e.VIC,County,State,Variance,etc.). ft. ft. . 'it
3.Well Use(check well use): ft. ft.
S.tha
Water Supply FVell: • . . 17:SCREEN,l.,:. .:;.,f:, .....,•-...,:•1_-.;::.l.,:-1.F:..',..:',.]:::',..-.;,.;'..;.7-i.•',....i./,.7l-;•;:;•:...„.1' .:,-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
.1 Agricultural 0 Municipal/Public • ft. .ft. in.
I Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft • in.
MIE-dustri omraerckResidential Water Supply(shared) ...
'is:-GROtTD: ., -l: fit:....•''''',--:-.:''?":-.1-:1(..---''''t '':';l•: .::-:-..'7. t' 'i'-'::-.,
Irrigation FROM TO MATERIAL EMP4, EMENT METHOD&imotfttr .
Non-Water Supply Well: 0 ft• 20 ft benimate. poured
Monitoring Recovery - ft. ft
Injection.Well: , ft. ft.
Aquifer Recharge 0 Groundwater Remediation •
.19:SMID/GRA.VELTASCX(if 4iilicabre)"•..;-'••7.;.•••-•••••:-..:•A•-••:-3''..•:•.:''''''''':.-":•••Aquifer Storage and Recddvery Ell Salinity Barrier FROM TO • MATERIAL . EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage • ft. ft. • .
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer . . :28.:DRILUNG.LOG(httiElfidditidlial ikeetkif iiReEsalf91',-."-.7:"..l•,-.l ::$•."-:-'1..:::V.,..77.'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
e Geothermal(Heating/Cooling Return) jOther(explain under#21 Remarks) • .
b •ft- 5 C)
4.Date Well(s)Completed:\k (1%1 Di Well ID# 56 ft tab ' bvtusix rod( .
5a.Well Location:Z WA>ft. 2416 bkur- r.hckf.._., • •tock.\& Ktviityo ftk• .
• ft , , •
- .....-
, i. i
Facility/Owner Name Facility lD#(if applic-a.ble) R. ft. ' t i I r-, 191
C11-1447trY9supre SokAalti Al e-zs tst-c, ft. fr.
,I •
Ph sical Address,City,end ' -J ft. ft.
.
CA;Aik 2)t 5 .-2..1az.vs64.Rxs .;:,;.--,,--.7 7....:,;..,.....::.:, ,..r.,..--..:.-.?.:.:-,',,,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient)
4.cation:2..: ). . .
35.Upt, -1,1 SO.42to 1. -vs, _
J.:.
6.Is(are)the well(s)i*Perrnanent or EllTemporary Signa,f .fl"rtified Well Contractor -Date s.
B 411Kning 1r is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or iliNo with 15A NA.-C 02C.0100 or 15A NalC 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 this record has been provided to the well owner.
repair under A121 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: - 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2,00 (ft) 24a. For All Wells: Submit this form within 30 dap of completion of well
For multiple.welfr list all depths i f different(ecatnple-3@,200'and 2@..100') construction to the following.
10.Static water level below top of casing: 4' (ft) Division of Water Resources,Information Processing Unit, •
1fwater level is above casing;use"+''
1617 Mail Service Center,Raleigh,NC 27699-1617
-. 11.Borehole diameter: 6 (n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
. above,also submit one copy of this form within 30 days of completion of well
• 12.Well construction method: r o—t—oi Y.ci . - construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) • •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) k . 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
<4, .
13b.Disinfection typetWOrtiN6 Amount: ib oz.. completion of well construction to the county health department of the county
where construtted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . •
Revised 2-22-2016
' . .. —..,