GW1-2023-02155_Well Construction - GW1_20230306

I.W .. o�ntraetor lnf oration: • jj�l S vf-c.-\k. W��,_ ei \dc,Vt sl j v e_• f
A ' i feiti'1'1JVC.& 4-0-S'' 3 k -Q \L1...a' d 1n f
•
Well Con for ( 5 l'A r0 V Chun') rr
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ft. I ft
NC Well Contractor Cerli cation Number I. '15:O U'1'k12:CASTh G',(fer mniti=rased wens)OR r-:rrn•• if appl cable)':s ;':, •.
Morgan Well&Pump;Inc. . FROM f TO' DIAMETER THIC:EsESS MATERIAL
• Company Name +1 ft / k ft 61181 I '' sdi21 pvc
�1� '7 J� iti�II�EitCASDIGOI2.11).er g(ge6tlefmal.clo'sedlode)!..;::.--.•_• .;%••••�':-
• 2.Well Construction PermitB: �J FROM TO DIAMETER . THICmNESS MATERIAL'
List all applicable well construction perinits'(Le.UIC,County,Stale,Variance,etc.). ft. ft. . iu.
•3.Well Use(check well use): ft. ft. Sin-
.
• Water Supply Well: 17.-SCREEN', .. - . .: . r,.- • ..:,-
PROM TO '.-,•DIAMETER SLOT SIZE• THICKNESS IMMATERIAL '-
Agricultural . , DMunicipaUPublic . fr. .ft. in.
Geothermal(Heating)Cooling Supply) f;Residential Water Supply(single) ft ft. in
ThRustrial/Commercial JResideniial Water Supply(shared) -_:r.,,- __• _.
:'Iai ation ::75:GROUT•::••..:. =. . �"_. .... _ . :•._.'. . •:',_--- _ ;..'_";,•;•.
g - . FROM TO MATERIAL EMP~ CEMENTMETHOB&AMOUNT
Non-Water Supply Well: o ft 20 it bentanite• poured
Monitoring. DRecovery ft ft.
_Injection.Well: _
ft ' ft.
Aquifer Recharge DI GroundwaterRemediation '
Aquifer Storage and Rec&Very •DSalinity Bawer PROM
SAND/GRAVEL'PA CK(if applicable)'',:;. _ :_ :'. .."i'i`•:.'•'.i C:"
MATERIAL • EMPLACEMENT METHOD
Aquifer Test • • DiStormwater Drainage ft ft.. • •
Experimental Technology ©j(Subsidence Control ft. ft
i Geothermal(Closed Loop) • DTracer . - , :20.DRIILIIIG.L'OG•(attacli dditionalsheetsjfaecefsary7 "-r.::•_:s ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To eDESCRIP tohardness,saiUrock type grain size,etc.)
•a • t
` ft ft Cd).A`7►d`4_Date Well(s)Completeda k� �� Well ID# 3 ft. S
Sa Well Location: _
7 J
Facility/Owner Name Facility ID0(if applicable) ft ft. ?
�1 t Il�� it�i . R, NV ft. ft • "�AR ? ?
E18srcalAddress,City,and Zip ft ft --•,•... .:.,J !.'; 1.
-r i L . . . 63Q (3 60y®(_� -. ..:,,:.- •-:r- . •
_ _ - -
d'�'i °"z1:
County Parcel Identification No.(PIN) _ 1 c5 l �d ?i,l, fie rJr� s`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneone 1st/long is sufncient) Cy 2 ration'
35
._.. .v..:- .4.8
6.Is(are)the well(s) Permanent or 0Temporary Signs f ' ed Well Contractor •Date
B going is form,I hereby cernfy that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: lJYes or•L.;No with 154 C 02C.0100 or ISA NCAC 02C-.0200 Weil Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of Ali record has been provided to the well owner.
repair under 421 remarks section.or on the back of this form.
• 23.Site diagram of additional well details:
8-For Geoprob'e/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 land surface: .(/G•5D (R) 24a. For All Wells: Submit this foam within 30 days of completion of well
For multiple wells Gist all depths ifd�erent(erarnple-3@200'and 2@.100) construction to the following.
10_Static water level below top of casing: l V (ft) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor:ehoIe diameter: 6 (in.) 24b.For Infection FVells: •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 U construction to the following:
(.e.auger,rotary,cable,directpusb,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) 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 typ Amount: ---P completion of well construction to the county health department of the county •
where construbted_
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016