GW1--03012_Well Construction - GW1_20230306

]..W ontracfor Inf -oration:
-14:.WATERZONES
Well Connact&arne- FROM TO DESCRIPTION
!(A', ft ft
fL
NC Well Contractor Certification Nmnber
` IS:OUTER:G�A6INg,:0r,&mZijseawva s)C9MENE Cif
Morgan Well.&Pump;Inc. FROM TO' DIAMETER THlcrt aec MATERIAL
Company Name +1 ft' ft 61181 mi sd,21 pvc
A 16.-DMR CAM G OR•TURI14G
2,Well Construction:P t#:�J f ' FROM TO DIAMETER, i THICKNESS MATERIAL'
List all applicable well consA'uc&on permits a &M,,County,State,Variance,etc)• ft ft in.
3.well Use(check well use): R in.
Water Supply Well: 11"SCREEN'._ = -
FROM TO DIAMETER SLOT SIZE •THICKNESS TVIATERIAL_,
Agricultural 0MuniciP l/Public ft in.
Geothermal(Heating/Cooling Supply) #Residential Water Supply(single) ft fz in
I Jnndustrial/Commercial Residmfial Water Supply(shared)
Ini lion FROM TO - :MATERIAL F� .CEMENTMET$OIi&AMONT
Non-Water Supply Well: o ft 20 $ bentonite• poured
Monitoring Recovery ft ft
injection.We1i:
ft ft
_-Aquifer Recharge I�C-aoundwatexRemediation
Aquifer Storage and RecMvery Salmi Bawer �:SdND/GRAVEL'P9 CK tf a'lica6le ':.:;:=';:: :'-;._'::•. •..'i.':_'
n t5 FROM TO MATERIAL ' EMPLACEME14T METHOD
_I Aquifer Test 0stormwater Drainage ft .
I Experimental Technology OI Subsidence Control ft ft.
iGeothermal(ClosedLoop) Tracer :20�I)RILIMGLOG'(aftacli`additionslslteefsjfnecess-7';�;:_.; =_
Geothermal(Heating/CoolinaReffim) J Other(explainunder#21Rema13cs) FR TO ➢ESCRIPTION(color,hardness,soiUmcktype grain sae ere)
r. f I- ft 1114
4.Date Wells)Completed:v �f! G� Well ID# ft ft
Sa.Well'Location: ft ft p 1 O
Bqa,� IVI .)
.+�•i ii:�;ri;� 'fir
Facili Owner Name Facility]D#(ifapplicable) xis '„o'`'�":1?., Ltf3
eb b " fir ' L kxll NL t� ft. _cv:
Physical Address,City,and Zip ft ft
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwellfield,one lat/long is sufficient) 1 2 ration:
JCJ(�46 g W AX
6.Is(are)the well(s) Permanent or ©'•ITemporary, Si e f rtified Well Contractor Datfi
-Biz.ring is form,I hereby certr•fy that the we11(s)was(were)constructed in accordance
7.IS this a repair to an existing well: X or.'§No wuh 15AN C 02C-0100 ar 15A NCAC 02C.0200 FPell Construction Standards and that a
Ifihis is a repair,fR out brawn W-0 constr=d ormation and explain the nature of the copy ofthfs record has beenprovided to She well'awner.
repair under 01 remarla•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 bf wells construction details. You may also attach additional pages ifnecessary.
drilled; s1 / STJBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�� (ft) 24a,For All WeIIs: Submit this form within 30 days of completion of well
For multrple wells list all depths ifdiierew(example-3 n200'and 2@I00) construction to the following.
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifwoter level is above casino use 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
• �12.Well construction metho d- ��L . construction to the following:
(Le-anger,rotary,cable,directpush,etc.)�� g'
FOR WATER SUPPLX WELLS ONLY- Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Water SuPpiv&Iniection Welk:Iniection 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 typ A-mount�pZ completion of well construction to the county health department of the county
where consructed_
Form GW-1 North Carolina Department of Environments!Quality-Division of Water Resources Revised 2 22 2016