GW1-2023-02494_Well Construction - GW1_20230406

vv.mLL,LU1Nb 1xCU t_:AIUNN RECORD(GW-1) For Internal Use Only,, • -
1.W ontractorinf -oration: ' •
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•14:.WAuaZONES•:. : :. -_••,..^.:' .:••.,.... ...._:.:, :.-.. •_
Well Con for gore • ' FROM TO _DESCRIPTION
- 42_ A , r ft ft
NC Well Contractor Certification Number
., _ ••-
'15:O U.le;.L CASING,(fo"r multi=raped web I.l s)OI2T(ER(if ap licahle)' :::.::': •-
Morgan Well&Pump, Inc. . FROM TO' DIAMETER THICKNESS MATERIAL, TERIA
Company Name +1 ft G i ft6 1/8/ in' sdr21 PVC
n w ��� 16.`TIVER CAB DIG OR•1U_BING'(keothermaZ.rsI6'se&ltiap)/.`:.:''-1," r6% " '• .
2.Well Construction Permit#: (f�,) FROM TO DIAMETER THICKNESS MATERIAL- .
List all applicable well consbuction permits'(t.e.WC,County,State,Variance,era)• ft' ft• . in. •
3.Well Use(check well use): ft ft' in.
r,i:. ::.-•:_...yt,.: "•' ...:
Water Supply Well: •.•.•:...•.��.. ,,:-,....... �.,.•. ..-. .-.
FROM TO DIAMETER SLOT SIZE THICKNESS ➢•IATERIAL.
DAgiicultural 1Municipal/Public ft ft in.
, 0 Geothermal(Heating/Cooling Supply) PResidenfial Water Supply(single) ft • . ft. in.
DrndustriallCommercial pResidential Water Supply(shared) :.::,: Y-:- .:_=•;.•; :: ..
:18:GROUT.: =- :- __.,.•-,..
0linigation FROM TO MATERIAL EMPLACEMENT METHOD&_4MOUNT
Non-Water Supply Well: o ft 20 ft• bentonite• poured
Monitoring DRecovery ft. ft. •
Injection.Well: ft. ft
_J Aquifer Recharge Ei Groundwater Remediation •:.19:SAND/GRAVEL'PACK(if applicable)•-'.:_.-=::•,'. :_''::'.-'..':' 1.:.'•'.:-:'•..
Aquifer Storage and Recovery DSalinity Barrier FROM TO • I MATERIAL - EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft. '
I Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer - , :ZO.DRILL I NG.LOG-(attaeli-additional sheets-if inecessary)' *-.:'•t= :6-••.'• ,11:•
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM _TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
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0 .ft D-5 ft rr-d Auk
4.Date Well(s)Completed: 1�� a3 Well ID# a5. ft 4 b ft .bra a .
5& caWell Lotion: 46 ft (pc) ft +jda*t roc,,{[ . • •
�n1t4 ft 30b ft 4avt, gYaril-G
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Facility/Owner N Facility ID#(if applicable) ft. ft
2W S\ x.1Zd bilk OWL Mc- 2,S kas ft. ft. ', ;_.. • - �i
e:
/Phhysical Address,City,and Zip ft. ft p n I '(1
County Parcel Identification No.(PIN) infc.;iy:af ';1 p ,,,-_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) /_3q l n 2 cation:
3S � �
�� N�0.to W .?J
6.Is(are)the well(s) (Permanent or OTemporary Signa e f ' ed Well Contractor •D e
• B going is form,.1 hereby certD,that the well(s) was(were)constructed in accordance
- 7.Is this a repair to an existing well: ©'Yes or *No with 15.4 C 02C_0100 or 15A NCAC 020,0200 Well Construction Standards and that a •
If this is a repair fill out known web'construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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.
drilled: . - ‘ SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: Sob (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple'wells list all depths D.-different*ample-3 cr 00'and 2@100`) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, •
,Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
..y-' r I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: U ., construction to the following:
(Le.auger,rotary,cable,direct push,etc.) • ' '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) to - Method of test air pressure 24c.For Water Supply&Injection 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 type''r v6 Amount: `k eiz, completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources . , Revised 2 22 2016
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