GW1-2023-02213_Well Construction - GW1_20230307

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1.Well Contractor Information:
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•14:.WATER ZONES : '' :: .. .._ . ._
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Well Con r Name ' ' FROM TO DESCRIPTION
� ' (�( '
/i.,�, it ft
"� ft ft
NC Well Contractor Certification Number
'15:O'0TERCASING,(foi multi=ca$ea wells)OR FINER(Waft'livable)'1 ::',: •.`.:
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Morgan Well &Pump, Inc. : FROM 4DIAMETER TRIMNESS MATERIAL
Company Name • +1 ft � 6 1/8/ ia, sdr21 pvc
16."IlQNER CASING OR•Tu.SENG:(geiitliecrmal'closed--l66p)I.€:."''•a' <:•:'.''•' ':.
2.Well Construction Permit#: 394"4)14 ri FROM TO DIAMETER I THICKNESS MATERIAL'
List all applicable well constructionpermits(i.e.UIC,County,State,Yaiance,etc.)• ft ft . in. •
3.Well Use(check well use): ft ft. in.
Water Supply Well: . 17.SCREEN',.:•.. '•• ._ . :'f::-.:>;.--.. . ..
� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural ! 1Municipa]/Public ' • ft ft in.
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Geothermal(Heating/Cooling Supply) ;:Residential Water Supply(single) ft • , ft. in.
1 Eilustrial/Commercial ]Residential Water Supply(shared) :r18r GROIIT:;." .. .. . .`-' '
Irrigation . _FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: 0 ft 20 ft bentonite poured
' Monitoring Recovery - ft ft.
Injection-Well: -
ft ft
Aquifer Recharge 0 Groundwater Remediation _
:.79:SAND/GRAVEL'PACK(if applicable)•':.:>._' ::':' '. ,' '•' :
Aquifer Storage and Recovery Ell Sa linity Barrier FROM TO • MATERIAL • EMPLACEMENT METHOD
Aquifer Test IStormwater Drainage • ft. ft. '
Experimental Technology D Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer . , :20.1)RMEING.T,OG'(attach'additionil s eetiff aecessary"j'•s. :•`=s
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type grain size,ere)
rb ft tc ft bfowti dtrt-
4.Date Well(s)Completede/22-P:5 Well ID# L .. ft 36 R• kjraW t, va6
5a.Well!L-ocation: 3m ft ua ft. 'b1�oL Y - • •
VwicY 1 \d`t k�,,vl ft ft •
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Facility/ ner Name Facility ID//(if applicable) ft ft.
1(13C ein &ro 3 ft ft. . ..:r-r It L.. ,
ysical At dress,City,and ZipV.
ft ft
�y,�_ aRu
. 13i' ac °21S72FNL__S'; ..: f` .`:i =J4iLl),ui 4:.A/'-?AlI L:•r+. ..,... -..
County Parcel Identification No.(PIN) y lS .
E:l.•:in;::.:=:i :•i..
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) tification:
2-PFLitag____
6.Is(are)the well(s)MPermanent or DTemporary Si= o Certified Well Contractor •Dat
B sja:in 1 is form,I hereby certify that the well(s)was(were)constructed in accordance
'7.Is this a repair to an existing well: JYes or No i 154 AC 02C.0100 or 154 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 421 remarks section or on the back of this form.
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• 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•ofwells construction details. You may also attach additional pages if necessary.
drilled: • SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 0142 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following'.
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10.Static water level below top of casing: Li,K c) (ft) Division of Water Resources,Information Processing Unit, •
.Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection'Wells: In addition to sending the form to the address in 24a
p above,also submit one copy of this form within 30 days of completion of well
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12.Well construction method: - 1 Ir(-, construction to the following:
(Le.auger,rotary,cable,direct push,etc.) . • .
' Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) u • Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
4:1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ't8,,,,,,, Amount: (Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2 22 2016