GW1-2023-01801_Well Construction - GW1_20230213

1.W 'ontractor mation: •.
I I
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Well Co ame A FROM TO DESCRIPTION
. ' "M2-i -A ft ft. ' •
NC Well Contractor CertiOcation Number ,
$15:0 ir,Mit.,CASING,(foi•riniltiLdiseaiiills)OILINEE.(trap'lit-0,14.7.::::'!....:1".."•;
• Morgan Well &Pump, Inc. : FROM TO' DIAMETER THEIFEsIESS MATERIAL
•
+1 ft• 4.6 ft. In.
6 1/8/ sdr21 pvc
Company Name '
167),NNER CASING OR•IIIWNG:(06th"erinal"Clisised.-lo-ciP)1. '.''
2.Well Construction Permit#: 348. 14-1a" -- FROM TO , DIAMETER THICKNESS MATERIAL
List all applicable well construction permits:(i.e.UIC County,State,Variance,etc..)- ft. ft. in. •
3.Well Use(check well use): ft ft
S.in.
Water Supply Well: - , . 17:SCREEN',....,:...-;.:,•.•_.,_, .-"..........•;-:-.....-.-_'..,:•-.-F1-...:_•:::::.".•,1:... ,,,....,• ;:......i.),. ::-.i.;:•••:,
FROM TO DIAMETER SLOT Stz,g THICKNESS MATERIAL.
NE Agricultural 0 Municipal/Public ' ft. ft in.
X Geothermal(Heating/Cooling Supply) 41Residential Water Supply(single) ft • ... ft. in.
0E-Mistrial/Commercial UResidential Water Supply(shared) ...:18:.GRotrr.: .-:: ..:-...,.-,-.:r . •,-. :':.:7.: .. :::•:-''.•••'.-!1.--2•'-';.!.:-•
Illtrigation . FROM TO misnacUAL EMT CEMENT METHOD.&imam .
Non-Water Supply Well: 0 ft 20 it bentonite poured
XI Monitoring CiRecovery . ft. ft.
injection.Well: -
ft. • ft
M'Aquifer Recharge 0 Groundwater Remediation
•!.19:SAND/GRAVEL•PA:t7(if kpiiiicabre)•-:'.;. ,-'':;'.i..... :_"':..•. -.."-i-,!'"..'•"..:'","')...'...".".
*Aquifer Storage and Recddvery D SR linity Bather
-FROM TO • MATERIAL • EMPLACEMENT METHOD
•
" •Aquifer Test nStormwater Drainage ft. ft..
70 Experimental Technology D Subsidence Control ft. ft
• 01 Geothermal(Closed Loop) D Tracer .'20.1=ING.LOG(ittiCliiidditithial iffeetkif itiReisft.77 s..:.•;.', s'*--.'.7. -,-..f.:V...'...'•:'
OM TO DESCRIPTION(calor,hardness,soil/rock type,grain size,etc.)
,-. Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) .PR
6 .' >5 it 6(tnain t‘trk" .
4.Date Well(s)Completed: \\.12.$127_,Well ED# DS: " 40 ft• klaritetn tbi le •
5a.Well Location: '.(C) ft 450
- elleorkt e3;,:larcv, , ft.
ft. .3 • ., ''--r)
Facility/Owner Name Facility ID#(if applicable) ft. ft .. F 6 1
3ck5S Nit kkut. 152.N4 Of,w,k, CM c AtC ft. ft.
P ical Address,City,and Zip ft. ft. ;flI,...., , .,,:. ! : ,, . .:......,:-,j1.,n,i
.. ...... — .— •" ..>"' ••
• -'11a:EDIcARIcs".-:-.i:i:,;: .,---:,':-.•:: ':...7'll--1-4''..“.:. ---;--;..7-:••••••:- :V.-',V.,..f....?.-! :•:::
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:
.3S•SCCICI.0 "N 96.(04.111 W .
......
6.Is(are)the well(s)*Permanent or 0 Temporary Signat": fr rtified Well Contractor
B 1,:,,,ning is form,I hereby certify that the well(s)was(were)constructed in accordance ,
7.Is this a repair to an existing well: EiYes or *No with 15A ,i,'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 evkdn the nature of the copy of this record has been provided to the well owner.
- repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well derailg:
8.For Geoprobe/DPT or Dosed-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
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9.Total well depth below land surface: 11. C) (ft,) 24a. For All W'ells: Submit this form within 30 days of completion of well
For multiple.wells list all depths y'different(example-3@.200'mid 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
-. 11.Borehole diameter: 6 (in.) 24b.For Infection Wells. In addition to sending the form to the address in 24a
... above,also submit one copy 12.Well construction method: 10-k01 . of this form within 30 days of completion of well
• ti . construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) • •
FOR WATER SDPPLY WELLS ONLY:
13a.Yield(gpm) C.) Method of test air pressure
13b.Disinfection typ Amount di OZ. ' Division of Water Resources,Underground Injection Control Program, .
1636 Mail Service Center,Raleigh,NC 27699-1636
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
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
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