GW1-2023-02156_Well Construction - GW1_20230306

1.W ontractor] oration: . 1 I
•14:.WATER ZONES-,•. __ ... •.. •.„ ..•_. • .
Well Co for ame • ' •- FROM TO _DESCRIPTION ~
_A ft.
T ft. ft.
NC Well Contractor Certcation Number
i •15;Ou:r.M.:GASZNG,(foc multi=cisea walls)OP:kar a(Tap'licable)'1 ::::• •."._
• Morgan Well&Pump;Inc. : FROM DIAMETER THICICIESS MATERIAL
. Company Name -Pi ft. ft 6 10iP• sd21 pvc
j'� Ir� 1611TID R CASING°R•:uB1N6.fatitheana7 dn'se3Iodp)..:` ••;' -1:-; ''•• -
.2.Well Construction Permit#: �k v ci,w FROM TO DIAMETER , TIC SS MATERIAL' .
List all applicable well constructionperniits'(te.WC,County Stale,Variance,etc.). ft •. ft. tn•
•3.Well Use(check well use): ft ft in
•
Water Supply Well: 17."SCREEN', _. .••._.\. _L.' .
FROM TO DIAMETER SLOT SIZE .THICKNESS -MATERIAL•
Agricultural .Di Mnnicipal/Public • • ft ft in.
Geothermal(Heating/Cooling Supply) Dn Residential Water Supply(single)
1^ndustrial/Commercial *Residential Water Supply(shared) '.. _ in. _ _
::'18;GROUT•:--.' '- -:r•gin.:,:...:.,. .,-. ..• ••. .,
!Irrigation . . FROM TO ::•MATERIAL c: . EMP~ CEMENT METHOD&:AMOUNT .
Non-Water Supply Well: o ft 20 ft. bentonite• poured
Monitoring. DRecovery - ft. ft.
_Injection.WeIl•
ft. ft.
Aquifer Recharge D Groundwater Remedia]ion •
Aquifer Storage and Recovery ISa unity Barrier FROST/GPAVEL•PACK(if appficabre)•*:•.;:_=:: •,:-'•::•.-•.:;';`_:':•-:'•%�'.'
MATERIAL • EMPLACEMENT METHOD
' Aquifer Test - • J Stormwater Drainage • ft ft• •
apelimental Technology 0 Subsidence Control • ft ft.
i Geothermal(Closed Loop) - •DTracer . , :20.DRILLING.LOG•(aftacli'addifioialslleetsifaecessar):::' :•t-
• Geothermal(Heating/Cooling Return Other ex lainunder#21Remarks FROM. TO DESCRIPTION(color,harddnes,soil/roektype grain size,etc.)
r. (A ,g i ) j ( P - ) 't '1iD ft- 4l �• `,)
4.Date Well(s)Completed: f�-1 / t 119 ell ID# CYt `>VO• ��--••��-'c a)��"' �-
111 4b ft ae✓d.J� � �lex&e._,� `
Sa Well Location: )p•
ftt"�
Fajilc�ity/Owner Name • Facility ID#(if applicable) ft. ft
Physical Address,City,and Zip '(�/ (/^ ft. ft MAR lJ /02.
c- i"'w 6k,. 4� 6+ `�`fl �'R .M6RTIC •`i' _. ..-_..� -:: ''�'-__ ':F- _•. V_.L.11 ;`: :.
;77.
County Parcel Identification No.(PIN) - r •: . '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 2 cation: \ •
^�pper�
� �r � NICZD ' Si W r O�
6.Is(are)the well(s) Permanent or DTemporary Signa f ' ed Well Contractor •Date
B fining is form,I hereby cern),that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or.141No with 15AN C 02C.0100 or 15,1 NCAC 02C:0200 Well Construction Standards and that a
Ifthis is a repair,fII out known well construction information and explain the nature of the copy of Mil record has been provided to the well owner.
repair under 3V21 remarks section or on the back of this form.
• 23.Site diagram otr additional well detail¢:
-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: • . . SUBMITTAL INSTRUCTIONS
. 9.Total well depth.below land surface: 3 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(ncample-3(200'and 2(a100) construction to the following.
•
10.Static water level below top of casing: .,c (ft.) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casing,use"f" 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
•
•y—(I j
of this form within 30 days of completion of wellt d construction to the following.
(1..e.auger,rotary,cable,direct push,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 typel or
J'W Amount: EYL.- 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
i