GW1-2023-02159_Well Construction - GW1_20230306

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__1eil Coniract�Information:. _4_A 14:.WA1k t ZONES
Well Coutx3Gfc�i•Name • • FROM TO ,•DESCRIPTION•
ft ft.
' - Lk ft ft. '
NC Well Contractor Certification Number
'15:O U.1'k:R:QASING,(for multi-cased wells)O .L I'ER dap'licable)' •-
Morgan Well &Pump, Inc. . FROM TO• DIAMETER THIcRI1ESS MATERIAL
+1 ft. 1 ft 61/8/ ii' sdr21 pvc
Company Name V 67�
/�'iti"1("-- 16"IlVNER CASING OR..c u.sI NG:(�eotliefinaT'prised-lode)!.:`>;'=' :•:•• ;`''•2.Well Cohstrtiction Permit#: C 1 l7>EyT `-�/. FRoM TO -DIAMETER _ THICKNESS MATERIAL'
List all applicable well construction permits(i.e.WC,County Stale,Variance,etc.)• ft ft . in. •
3.Well Use(check well use): ft. ft in.
Water Supply Well: . 17_SCREEN',.:, :=:,-. .'•.-<'•. •::• 1,,:.4:•i:r.::•,::- •�,::::.;:-i:•:.::•.:.•.:::' .=:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public . ft ft in.
Geothermal(Heating/Cooling Supply) .ZResidential Water Supply(single) ft • . ft hi.
Industrial/Commercial JResidential Water Supply(shared) :18:GROIIT•.. ":: _ -:,. •-:--.... • _
Irrigation . FROM TO MATERIAL EMPLACEMENT METHOD&_AMOUNT .
Non-Water Supply Well: o ft 20 ft benionite• poured
Monitoring DRecovery I • ft ft. .
_Injection.Well: -
�—,� ft ft.
E
Aquifer Recharge f Groundwater Remediation
:.-19:SAND/GRAVEL•PACK(if applicable)•'•'.c::: ::•i.' '
Aquifer Storage and Recovery DSaUnity Barrier FROM TO • MATERIAL • EMPLACEMENT METHOD ~
Aquifer Test OStormwater Drainage ft ft. •
Experimental Technology DISubsidence Control ft ft.
Geothermal(Closed Loop) Tracer . , :20.DRILLING.L'OG(attach'addi.tionalslieett.fiecessary)::'{ '•t=;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft reel dk*
TO DESCRIPTION(cola,hardness,soil/rock type gra n s ze etc)
r •
4.Date Well(s)Completeda- ,,� \ We11ID# \t) ft. 35 ft.ft. v\ at*
W,eell1L,ocation: / `4 �t c 6)',\ . -,;. ,is ;--~- s
bit J✓
Facility/Owner Name Facility ID#(if applicable) ft ft M ri-\R k, ;? i0.6
Ph siic�alAddress,City,and Zip ft ft ;C.i;s°w{;;
County Parcel Identification No.(PIN) htf— i-3
43, -4‘k"") .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
2(if well field,one 1at/long is sufficient) 22 a tiflcation'
5, ....S)2.7.- "N It) trictki. -cv atyiji _, ..,..1
6.Is(are)the well(s),;_--)Permanent or ElITemporary Sid ji,,e ou rtified We ontractor •Date
B• :in: .rm,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: QJ Yes or . 'No w r 15A •JT' 02C.0I00 or 15A 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#21 remarks section or on the back of this form. • 23.Site diagram or additional well details
8.For Geoprobe/DPT or nosed-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 NUIvIDER'of wells construction details. You may also attach additional pages if necessary.
drilled. - I SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: � (ft) 24a. For All Wells: Submit this form within 30 dayb of completion of well
For multiple wells list all depths ifdl�erent(example-3(200'and 2@100')
construction to the following.
10.Static water level below top of casing: 45 (ft) Division of Water Resources,Information Processing Unit, •
Ifwater level is above casino 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 of this form within 30 days of completion of well
12.Well construction method: r u' (r construction to the following.
(i.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) 1 5 •
_ 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& ,Anokv\,i) Amount: 140Zr 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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