GW1-2023-02216_Well Construction - GW1_20230307

1.W ontractor •mation: • J i I l i
I•
.14:.WAI•ER ZONES•t', :_ ..i... ... ,. .._. •
Well Con for ame • ' - FROM TO DESCRIPTION
qji _ ft ft
/"rJ� ft ft.
NC Well Contractor Certification Number
t 'IS:0 ti,a}R--CdSING,(io`r multi=raed wells)OR LIKE R Gray livable)'1 :::; •.
Morgan Well&Pump;Inc. . FROM TO' DIAMETER THICR.r1ESS MATERIAL
Company Name +1 ft 414 ft 61/8/ I P2' sdr21 pvc
• P Y
• (� l6 JP NCR CASING OIt•lUBING.(g Oftse-r isel'dlosed-lode)?.:`-.;`' :•:%' �'•...
2.Well Construction Permit#: ri FROM TO -DIAMETER i THICKNESS MATERIAL
List all applicable well consttuctionpermits'(xe.UIC,Count)).State,Variance,etc)* ft. . ft . ' in. •
-3.Well Use(check well use): ft ft a In
•
Water Supply Well: . 17_-SCREI,N', .._ _ -: ;,.-_ ,
MoM TO DIAMErE1. SLOT SIZE THICKNESS MATERIAL..:,--
Mom. . ji Municipal/Public • • ft fit in.
Geothermal(Heating/Cooling Supply) . (Residential Water Supply(single) ft • - ft in. •
i 7ndustrial/Commercial _ ]Residential Water Supply(shared) _,:tii_
::YB:GROUT•:: ": .; :.• :- L••7 _,.
!litigation . FROM To MATT IAA RMP.•`�CilaNT14rr,1 .OD&'MOUNT
• Non-Water Supply Well: • o ft• 20 ft- bentonite• poured .
*Monitoring. CiRecovery ft. ft. .
_Injection.Well- -
]'Aquifer Recharge 0Groundwate.rRemediation •fit •
• *Aquifer eandRecti e t Salinity Bawer •!. :SAND/GRAVEL•PA:CIC(ifapplicabl-e)•-:•:=. ::'.'`;.•.•,•. -•• -,,: `-'•--:'.!•'
.•�J q g ry .DIS ty FROM TO • MATERIAL • EMPLACEMENT METHOD
• *Aquifer Test • IStomiwater Drainage • ft. ft.. •
Experimental Technology ©i'I Subsidence Control • . ft ft
*Geothermal(Closed Loop) • QlTracer ' - , :20.DRI1.11ING.L'OG(attarlisddifionalshee£siFaecessar3-4;t :•=s -;.:;'c;�.':•
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION( lor,hardness seuh k type pain size,etc)
•
r 6 •ft IC ft brdI►' erlir
4.Date Well(s)Completed:21 ,' 3 Well ID# IS ft 35 ft 6131441.
41.r4Ir IC
5a.Well Location: %5 f• "seasft• Jthj %ray. C • .
• ,Facility/Owner Name • h Facility m#(if applicable) ft ft•
PhAddress, and Zip
ft I• _ 1'_,
m y, 3. Z7cl3R:21;lkraR B :;. ..— . . . ...:.:1 .__..;"�.�.,-- ; ti ?�,2. ...... --.
County PardelldentidcationNo.(PIN) i n° ,.., ;...'.l , _ `S ,•�1:,;' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
Of well field,one lat/long is sufficient) • •
r 2 � .cation: _
S.J12� N'a)A • W ' ' •• DI3
6.Is(are)the wells) Permanent or DTemporary. Signa.r rti£ed Well Contractor •Date
B Aligning is form,I hereby certify that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well: DYes or••No - with I5.4N,1•C 02C.0100 or 15rt 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 of this record has been provided to the well owner.
- repair under#21 remarks section'oron 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 I GW-1 is needed. Indicate TOTAL NUMBER*of wells construction details. You may also attach additional pages if necessary.
drilled: • `I, SUBMITTAL INSTRUCTIONS
•
. 9.Total well depth below Iand surface: (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd erent(example-3 ,200'and 2@100) construction to the following.
•
10.Static water level below top of casing: 46 (ft) Division of Water Resources,Information Processing Unit, •
Ifwater level is-above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
•
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: •In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
• construction to the following:
(i.e.auger,rotary,cable,directpush,etc.) . • .
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, .
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
e
13a_Yield(gpm) @,51 • Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
�I J r� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ (n Amount: 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 . I' I Revised 2-22-2016
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