GW1-2023-02496_Well Construction - GW1_20230406

vv_c11_,ti UU1N 1_KUU;l1UIN li.ECORD (GW-1) For Internal Use Only. • . •
1.W ontractor 1 •nation: ' •
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• •14:W.A.Luit ZONES c'• :_ Y.. ••• .. • • •
Well Co for are . • FROM TO DESCRIPTION
ft ft
' 342z -A t r ` ft ft
NC Well Contractor Certification Number
*15:(111s,u•iR_CA,SING,(fnc multi-rases*ells)QR BITER.arap livable)',::::'':,::'•.
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Morgan Well&Pump, Inc. . FROM TO' DIAMETER' THICKNESS MATERIAL
an +1 it. 13S ft 61/61 illsdr21 �pvc
Company y
Name 16.`IINNER CASING OR•IuBING.(�eotfiermal•cloiedlodp)..`:..;'"•a ' :'<:•:' ''' _.•• .
2.Well Construction Permit: � � 22 V� FROM _ TO DTAMFTER THICKNESS MATERIAL .
List all applicable well construction permits(e. WC,County,Stale,Variance,etc.)• ft ft . in. .
3.Well Use(check well use):
ft. ft. in
Water Supply Well: . 17.-SCREEN'..:•..:.'°_- =•`_.. .,::; f,.::•::a:;i. -:•.:.•.,:-..' .
• FROM TO DIAMETER SLOT SIZE TRTCFNESS MATERIAL.
Agricultural )Municipal/Public - ft, ft in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft - . ft in.
-)^ndustrial/Commercial UtiResidential Water Supply(shared) ,f/8:GROUT•:_.."' ,.-:t•^'" - .
birrigation . FROM TO MATERIAL EMPI 4CEMENTMETHOD&AMOUNT .
Non-Water Supply Well: o ft 20 ft bentonite- poured
Monitoring Recovery ft ft. •
Injection.Well: -
Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery DSalinityBarrier FFROM�/GRTo S• PAC I MATERIAL if e)•'• METH
OD
`
Aquifer Test DStormwater Drainage ft • ft. •
Experimental Technology Dj Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer . • :20.DRILEING.LOG'(attacli-addition'sl s eetsif iiaeiSaiii;+' i •r:4:
i Geothermal(Heating/Cooling Return) nailer(explain under#21 Rematics) FROM TO DESCRIPTION(color,hardness,scillrock type,grain size,etc.)r.
^ b-f �� ft rid t -
4.Date Well(s)Completed:,)le�•`1 O� Well ID# L��. ft l►i�'j ft' '��,p 1�.,�i .
5a.WellLocation: 4.S. ft. / Li'0 Yd c'k . ' '
�!W tbbh • ry0 ft t 9,5 f .
• Facility/Ow e Name Facility ID#(if applicable) q 5 ft `k5 ft- 6ritAIK rat(
LAW yic tt.aw,ktr- 31K6eyNe ZSSI,4C It S4 tift wary,_. lra.hitt.
sical Address,City,and Zip ft
• �. ..- _. r _ ,... :..
(I2 1 ��� .21:RF.MARTIR° `.i. i_; -1 -4
County Parcel Identification No.(PIN) /',P R 0 0 2 0 2 J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,onelat/long is sufficient) itl-i;=r r,: .:-:? r�r<`: .;,_.-•j l
1 �j 21Q 2 canon: '�'
6.Is(are)the well(s)4Permanent or Temporary
Signs e f rtified Well Contractor 3 I2q I
��
t
B o ring 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 15A C 02C.0100 or IAA 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 ofthii 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 derails 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: • . 1 SUBMITTAL INSTRUCTIONS
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9.Total well depth below Iand surface: iilit) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3 a00'and 2(100D construction to the following:2
10.Static water level below top of casing: SS (ft.) Division of Water Resources,Information Processing Unit, •
.Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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: Ut "r 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 276991636
13a.Yield(gpm) el • 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 typer 'r�'�j 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• . Revised 2 22 2016