GW1-2023-01803_Well Construction - GW1_20230213

rrLLL l_,UIva 1 IA.Ut,.1IUIN Ki t..U1CU ((.W-I) .. .For internal Use Only:
I.Well Contractor Information: .
7 4-� `.•14:.7WATER ZONES •. - :_ • c... .. ... ..
Well Contractor are FROM TO DESCRIPTION
f. f.
Ef -ill ft ft , ' .
NC ell Contractor Certification Number
's '15;OulE1,CASING',(foc multi-cased wells)OR LIIgE)t(Taff licable)':1 ",: ..
Morgan Well&Pump, Inc. - FROM TO'Tho DIAMETER THICEESS MATERIAL
Company Name +1 ft N ft 6 1/8/ in. sdr21 pvc
,� . 16:IN SINN R.NER C S-INAG OTUBING:(ge1thermal'claid_-1odp):.[:.:'"";' -
2.Well Construction Permit#: V q(1CY) FROM To DIAMETER THICKNESS MATERIAL
~
List all applicable well construction permits lie.I/lC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
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Water Supply Well: 1I SCREEN',:,:. .: x:' `:.:.= ;;i , _' ..-.:',_.;•:?. . :.... .::. .=:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Pablic ft. ft in.
i Geothermal(Heating/Cooling Supply) r'j)'esidential Water Supply(single) ft • . ft. in._
Industrial/Commercial Residential Water Supply(shared) _
:'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring ORecovery - ft. ft.
Injection Well: ft. ft.
I Aquifer Recharge OGroundwater Remediation
,.19:SAND/GRAVEL-PACK(if applicable)•':-.:_. ': _''::•. •..i.:''..'•'.:":'..:
Aquifer Storage and Recovery 0 Salinity Bamer FROM TO • MATERIAL EMPLACEMENT METHOD
Aquifer Test J]Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft ft.
Geothermal(Closed Loop) 0 Tracer :20.DRILLING.LOG'(attielldditiori'alsEeets.if ueceisary)'':''-:'•:'ems
1 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)•
FROM TO DESCRIPTION(color,hardne s,soil/rock type,grain size,etc.)
t ) ft. 1 S` ft sia, Y1 d i .
4.Date Well(s)Completed: F3o Z3 Well ID# f S ft VD ftr5a.Well Location: 9JO ftft , e-1 Aelf._S A oe-1 ' S3 ft 5 ft (214.,4
Facility/Owner Name Facility ID#(if applicable) ft. ft !/ a '"C' -,
2, ./Vc 4 �-[. ft. ft
Physical Address,City,and Zip ft ft. FLB 1 2023
Vitt(, �y/1 n-fc,,.'. rr.t
) • .-21:RFMXRKS=?-.... .. .r. �`".:_i,' ,:
County Parcel Identification No.(PIN) 3 v`, Lt,•3 V'_:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C +.••:r:on: •
3S1 7�� N .� � W ,/' L/ •. 3/-7.3
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6.Is(are)the well(s)�JiPermanent or Temporary SiL.ature of Certified Well Contractor Date
By signing this forms,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or 0JNo with 15A NCAC 02C.0100 or 1SA 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 ofthis record has been provided to the well owner.
repair under 4121 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 r,, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (16 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di erent(example-3(412000^0'and 2Qa 100) construction to the following:
10.Static water level below top of casing: W (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: r I above, also submit one copy of this form within 30 days of completion of well
J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS,tJNLX
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C)° 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 type:CIO`a/ (e Amount: ? CIL completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016