GW1-2023-02217_Well Construction - GW1_20230307

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1.Well Contractor Information_ I
G •14:.wATzos;, .:
Well Contactor Name FROM TO DESCRIPTION
1153 ` "1aoft. 24\ ft
• ft ft
NC Well Contractor Certification Number • •
i '15:0u.i: tit,GaSING.(fol.multi=rasea'ivells)bRLI[3R(ifap licable)' ;:::.•.:••. ..
Morgan Well&Pump, Inc. - FROM TO' DIAMETER' I THICSRESS MATERIAL
P Yame Com an N +1 f' 10 ft e 1/e/ I mj sdr21 �Pvc
` �^1 16:TMIER CASCING OR'ruBTOG.(Venthecmal'ai'se31o6p):.I:2-'—_' ::r•'•':..:':..
2.Well Construction
�Construction Permit#: PROM To DIAMETER ' THICKNESS MATstuAl,
List all applirnble well construction panels'ale WC,Cotnrij;State Valiance,eicf
it ft. in. '
• 3.Well Use(check well use): .
ft. ft. in.
Water Supply Well• . . 17.-SCREEN',=. _. -,. .'�• : :-t.. .::•::-1:. U: f,.:::: :::a�. -�:r.:.•.:::' .
}��y FROM TO DIAMETER SLOT SIZE `THICKNESS MATERIAL.
!✓J
Agricultural . Municipal/Public • ft ft in.
Geothermal(Heating/Cooling SuppIy). Wesirlential Water Supply(single) ft , , ft in.
Industrial/Commercial DResidential Water Supply(shared) :.78:GROUT.._...:; _-. . _.::.?'``''si .--.— - - -
P.Plnigation FROM TO M TERIAL EMPL.CEMENT METHOD.&AMOIINT .
Non-Water Supply Well: o ft 20 fc• bontonite• poured
**Monitoring DRecovery • ft. ft •
Injection Well: it
*Aquifer Recharge a GroundwaterRemediation . ft
!.79:SAND/GRAVEL-PASS(if appiithsr)".::=:: ' ''°
*Aquifer Storage and Recovery DSalinity Bander FROM TO • MATERIAL • EMPLACEMENT METHOD
**Aquifer Test J Stormwater Drainage • ft• ft. •
Experimental Technology DSubsidence Control ft ft.
I Geothermal(Closed Loop) DTracer .20.DRII1aiG1:OG'(Ott Eli-adoitiasil sheefs�fDeces'sary7'. ;�::-s :-••• :.7;'
I Geothermal(Heating/CooTingRetur) Other(explainunder#21 arks) FROM TO DEseRIPrION(hoio cranes soivrocktype grain size.,etc.)
�f_K� \J ft (� is �!►t„\ 1,(
?.Date Well(s)Completed: ` l��� Well Ib ,,1''c,�``. t L Lip f $((I,)�4),K
5a.Well Location: �•�lJ ft o ft SG,() S,/)VJ"t . '
�v n . . -7 ft.. ` ft sbWl`vcll'
Mc�'c�- n t c�
Facciiillityy//OwwnneerName Facility ID#(if applicable) �c f (- ft '��,trof G.r,i'( 5rr"A' c/
\G 7� r�Ot3(Ct,A \W Cle e.\ ft f
Phys. ddress,City,and Zip ffi ft f • "
�(v.. (l,r�( �(l� .21iaRlaarty.R=`-.ai;. .`-1" . - . ..:-.- ..._._:;`.- _.; -`ram' . .:. ._.
County��VV `�\`� Parcel Identification No.(PIN) ' M n R ; t; 7()23 .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(ifwell field,one lat/long is sufficient) .tfls;n 7;.1 i ::.Q :':
22.Certification:
'76 C)n .N / •G S-2c( (ue,r1 q 1.A1-)S
6.Is(are)the well(s) Permanent or pTemporary Signature of Certified Well Contractor •Date
By signing this form,I hereby certi that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well: DYes or 141No with 15.4 NCAC 02C.0100 or 15A NCAC O2C.O200 Well Construction Standards and that a
Ifni:is a repair,fill out known well construction information and explain the nature ofthe ,copy ofihis 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 GeoprobeMPT or Dosed-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 • SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �0 . (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.-wells list all depths y-cbfferent(example-3@,200'and 2@,100) construction to the following.
10.Static water level below top of casing: 1.j® (ft) Division of Water Resources,Information Processing Unit, •
,Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 •
•
I1.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a •
®y—(•)v r I above, also submit one copy of this form within 30 days of.completion of well
12.Well construction method: "` Li construction to the following
(ie.auger,rotary,cable,directpush,etc.) ' . '
•
Division of Water Resources,Underground Inf ection Control Program,
FOR WATER SDPPLT WALLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1 63 6
13a.Yield(gpm) 65 Method of test: air pressure 24c.For Water Supply&Injection Wells: In�,i tion to sending the form to
i} f\4 / the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type �' C�nv� Amount; �`\U V 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
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