GW1-2023-02214_Well Construction - GW1_20230307

1.W onfracforInf nation: • I I
•14:.WATERZONES,'. ;_
Well Con tar ame ' • FROM TO DESCRIPTION
•
• ' 342z -A ft it
ft ft
NC Well Contractor Certification Nmnbet
IS:O U.c.v2t CASING1(foi ninth=rases wells)OR 151sIER.WA plif-t-ap'; :?'•.".:
Morgan Well&Pump;Inc. : FROM TO' DIAMETER I THICKNESS MATERIAL
Company Name +1 fr' I 6t18J �' sdr21 1pvc
• 1S:INNlTER.CASING OR•1'UBING:j edtl a ina7•cldsed-lode)j';:.;'.•='is; '.;, ': :
2.Well ConstxuctionPermit#: st0.55DFROM TO DIAME.LAR THICKNESS MATERIAL'
_List all applicable well ction pe> .(i.e.UM,Coot v,State,Variance,etc.)- ft . ft. ' in. •
-3.Well Use(check well use): ft ft. S.ln
Water Supply Weil: 17.-SCREEN', . . _:, . _ = . . _-: 7.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural . . D!Mu nicipal/Public • ft. .ft in.
i Geothermal(Heating/Cooling Supply) ;_:iResidential Water Supply(single) ft • - ft in.
I Industrial/Commercial Lii Residential Water Supply(shared) ::18:G zotrz:;."- .,• ._.:",__.;.
,�''1bbrigation . _ . FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT ,
• Non-Water Supply Well: • o ft 20 ft bentonite• poured .
•
Monitoring. DRecovery ft ft.
jection•Well- _
�--, ft ft.
!Aquifer Recharge J Groundwater Remediation
. .•.19:SAND/GRAVEL'PA.CK(if applicabre)•':.::.. `;.':'. ._ :.•''. •.:`:'i I'1?•'::•:• ••C::
Aquifer Storage and Recovery ,LSalimityBamer FROM TO • MATERIAL • EMPLACEMENT METHOD
Aquifer Test _ • J Stormwater Drainage ft. ft..
•
i Experimental Technology 0Subsidence Control ft I ft.
Geothermal(Closed Loop) Tracer :20.M.1I,IINGLOG'attach=additibilal ifieetsaf riecess --
Geothermal(Eeating/Cooling Return) Maher(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiUrock type grain size,etc) '
b .ft 1,5 ft_ tkA
' 4.Date Wells)Completed:P'11.I X& Well ID# K• ft A6 ft 4orww' ciA14 •
a,Well.Location: ` • •
U -W. • Its ft. l7 ft .` Ql• �w
Facility/ rName 'J FacilitylD ifapplicable)
R ft �l — -
1 1 'Q/.0 itiNeaSrwc.NC- '*.0 ft 1 ft.Ph sical Address,City,and Zip ft ft iVI A R 0 P: 2023
lnanm AD arc :.•;_. ._ '::; ..:-•- _
County Parcel Identification No.(P1N)
-: ,(:)
•
•
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field_,one lat/long is sufncient) \ 2 - i.cation:
✓J. 1(OMN �o .10 L� • W .. .
?
JJrz/
6.Is(are)the wells) Permanent or DTemporary Sigma.a rtifed Well Contractor •Da
• B •gyring is form,.1 hereby cent•fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or.AiNo with 15A NA.C 02C_0100 or ISA NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair,,fill out blown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 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.
drifted: • SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: L.10.v (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifderent(example-3 a 00'and 2@100) construction to the following:
10.Static water level below top of casing: 3S (ft) Division of Water Resources,Information Processing Unit
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor:ehole diameter: 6 (in,) 24b.For Infection Wells: In addition to sending the foam to the address in 24a
-la—(;�v'd above, also submit one copy of this form within 30 days of completion of well
• a 12.Well construction method: 1 U ` construction to the following:
(Le auger,rotary,cable,direct push,eta) , . •
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,, ,
163614iail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c,For Water Supply&Infection 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 t3 P Amount: O �. 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