GW1-2023-02211_Well Construction - GW1_20230307

1.W oniractor 1 -matron: I
. •I4:.WAIIiR ZONES :_ ~ :
Well Con for ame ' ' - FROM TO DESCRIPTION
4jt r ft it
/il/I ft ft.
NC Well Contractor Certification Nu• mber , •
' '15:OU..110SR-CASING,(fo`rn u1ts casedweIls)OR EWER.(Tail hrahi)',./;•:j?.,•:- .-
Morgan Well &Pump;Inc. - FROM TO' DIAMETER - THICIMESS IYIATERIAL
• Company Name +1 ft. 44 ft 61/8/ ' Pl' sdr21 pvc
�(�/ �[c 1 Id. II ER CASING OR•1'UtiII�G:(gentliermai c1o'sed Ionp):.:`:. - _'
2.Well Construction Permit#: `(0 o ` FROM TO DIAMETER THICKNESS MATERIAL-
List all applicable well constructionpernuts'(ie.MC,County,State,Variance,eic.)• ft• ft• 4'. •
3.Well Use(check well use): ft ft Sin
Water Supply Well: . I7_-SCREI;IQ'. _,-. . . __: . .i;•"
FROM TO DrAMEtatt SLOT SIZE THICKNESS MATERIAL.
D Agricultural . , QMunicipal/Public ' ft ft in.
Geothermal(Heating/Cooling Supply) 1Residential Water Supply(single) ft ft in.
II lindustrjal/Commerciai Residential Water Supply(shared) ::18:GROUT:-- '. .. _.- _ r`-':•:%.:- ~: - -
bIuigation FROM TO _MATERIAL EEMT' CEMENTMETHOI3&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite• poured .
*Monitoring. Recovery - ft. ft
Injection.Well: ft ' ft
*A.quifer Recharge • 1 Groundwater Remediation . -
•:.79:SAPID/GRAVEL'PA:CK(if applicable)- '::< :• :'- ._'•:.'. •...r i-.t'.:••...- ?. '1•
*Aquifer Storage and Rec&very ,0Salinity Barney FROM TO • MATERIAL • EMPLACEMENT METHOD
' *Aquifer Test • QlStommwater Drainage • ft ft. •
•
Experimental Technology 0 Subsidence Control, ft ft
'Geothermal(Closed Loop) • 0Tracer ' - , :20.D12I111INGTOG(atticliaddition'ils'licetsjfrieceis2191;'I�'•`.�.i
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sell/rock type n size,eta) ,
ra Abr-
4.Date Well(s)Completed:2 I ci, I aZ well ID# 5: ft. ,j ft Ibiroin awl-
52.Well Location: ` VS ft SC) ft• e�N rock , • •
rl� �U1f�— ft 360 f` lava".
3&% ,
Facility/Owner Name • Facility lD#(if applicable) ft ft T
bCk� 0 U Dori Rel r` ti0,d RC,Zil3g ft. ft_ , ',...;.„„.v.,,.,.:fl ,„a :,IT_j L.
. Physical Address,City,and Zip ft. ft n r{ O D?
aNOPDV‘ .l rn 1 :2IERF.MARu4`,C.1.,.• °•`i j•.:c: -.....:...-_.:A.' =._5.1N' 1 ,.:$:1-._t':C;:7 :,....
County . Parcel Identification No.(PIN) i!::,i .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Sold,one lat/long is sufncient) i '
2 ,.cation: '
2_...............)
6.Is(are)the well(s)4'Permanent or CiITemporary Signe,!re "i rtified Well Contractor •Dat&1
Bung it form,I hereby ceitfy that the well(s)was(were)constructed in accordance
7.Is thin a repair to an existing well: Dyes or.;,_,No with 15ANh•C 02C.0100 or Ili NCAC 02C•.0200 Well Constnsction Standards and that a
If this is a repair,fill out/mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
- repair under#11 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: • Rh SUBIYIITTAL INSTRUCTIONS
•
9.Total well depth below Iand surface: 36C) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well •
For multiple wells list all depths ifdi)�erent(example-3 a 00'and 2@100) construction to the following.
10.Static-water level below top of casing: SO (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 Injection Wells: In addition to sending the form to the address in 24a
tot y( _[ above, also submit one copy of this form within 30 days of completion of well
• 12.Well construction method: J construction to the following:
(Le.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) 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 type(J I�l\I Amount: p�2, 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