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Home My WebLink AboutGW1-2023-02215_Well Construction - GW1_20230307 7;,. ....mod..,.:-, V Vi\L A i1V...w J.AV.L I.LWVV V.LW (Lr rv^a) cur lui.ZLuzu Uac uiuy: I i - N, . 1.Well Contractor Information:. G cac,,A--� (t 4L Se . . - 1Q:.WATER ZONES•;'. _ :: i ;:':i DESCRIPTION Well ��Co--jntritorName r Zgot ►f . '�755® ft "�b1 , NC Well Contractor Certification Number' • • •15;OUTER:CASING didi i nlfi=eisea vtens)OR 7 ER(if'ap licahle).-5 ::'..._' Morgan Well &Pump, Inc. FROM T DimEET2RI ; TlUcx;`rESS MATERIAL •Company Name• +1 �I ft• 6 1181 1,°' sdt21 pvc P Y 13�h CICI� U `� 1d:TrII tCASNGOP;LIMING.(eitiierma'lcla'sedlonp):.;:.."''•-' :;:•:%•`-:�'•.. 2.Well Construction Permit#: FROM TO DIAMETER THICR2IES5 MATERIAL List all applicable well construction permits'(ie.UIC,Cotmy,State,Variance,etc-)- ft ft. in.: • 3.Well Use(check well use): . ft. ft. O. Water Supply Wail: N',_=:: '`:.- .` •'•=•_.: :::'rt:.:: ;,.==.:`;:_>>. -�::..•.: :° .. FROM TO DWiTETER SLOT SIZE 4 TRIMNESS MATERIAL. Agricultural • Dr'Municipal/Public 1 SCREEft ft in. (Heating/Cooling Supply). .i Residential Water Supply(single) T. - ft - in. 1 Industrial/Commercial DResidential Water Supply(shared) thrigation FROM TO MATF!RIAT. EMPLACEMENT METIROD&AMOUNT . Non-Water Supply Well: 0 ft• 20 bentoniite. poured *Monitoring DRecovery • ft ft • Injection Well: *Aquifer Recharge 0 Groundwater Remediation ft fit • . ,.79:SAND/GRAYEL•PAC:K(if applickIFe)•' •` " '•r.c r'I.' ''-' t•• 'Aquifer Storage and Recovery EliSalinity Bru ier FROM TO • _MATER/AL • EMPLACEMENT METHOD *Aquifer Test DStormwater Drainage • ft.• ft • f Experimental Technology DSubsidence Control ft. ft. • *Geothermal(Closed Loop) DTracer :20.DRILLINGLOG'(strach'sdditional sheets 'aeceisary7•'.a: `t f='•.' I Geothermal(Heating/CoolingRetum) Other(explain under#21 arks) FROM TO DESCRIPTION(color,hastiness seWrecktype erarisre etc.) �—l1—Z3 > . Toma fr. ri24)h t);( . 4.Date Wells)Completed: Well ID# �S V ft' t� ft' g fotJ, )s A • 5a.Well Location: 60 ft (SS ft Sd s-v- \4--- . • cc/ n��cc__ . . .7''' 1 gC—ft 5-6:::. ft 5.,ct/ 5r I�-- Facrlt'ty/OwnerName ICJI F cilitp ID 1(if applicable) ft _ ___ __ cR'0 %J C l C. VC\ ft. ft , :: ‘.. .., .. Physical Address,City,and Zip ft ft • A A"-.E.-1:: r* r d� — Y k v � -2.naZE1(ZF�:?-:4:Pi;:-'•`.i:•-.:L, -._ - =..a tr,. `.••: CI�<-1.- :. County K Parcel Identlfccation No.(PIN) ; .:,.... ... .,j ,.. • • Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - (tfwellEel one latklong is sufficient) 22.Certification: ' S god •N �O,•( 7'156 le;-5,A,ee E? zerz.,1 6.Is(are)the well(s)APermanent or DTemporary Signature of Certified Well Contractor 'Date By signing this form,I hereby cermify that the well(s)was(were)constructed in accordance - 7.Is this a repair to an existing well: QYes or '4No with ISA NCAC 02C.0100 or ISA NCAC 02C•.0200 Well Consructian Standards and that a • If this is a repair;;fill out known well construction information and explain the nature of the copy of MI;record has been provided to the well owner. repair under#121 remarks section or on the back of this form. • 23.Site diagram or additional well details: • _ 8.For GeoprobelDPT 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 NUMIBER'of wells construction details. You may also attach additional pages if necessary. drilled • ‘ SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 6O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well - For multiple welks list all depths y'rb event(example-3(d200'and 2@100) construction to the following. 10.Static water level below top of casing: yo (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 • r f above, also submit one copy of this form within 30 days of.completion of well 12.Well construction method: r 0 vJl construction to the following: • - (Le.auger,rotary,cable,tltrectpvsh,etc.) - • Division of Water Resources,Underground Injection Control Program, . FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) � Method of test: d 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 �' C 13b.Disinfection type: o I Amount: `01/ 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 i I