GW1--03250_Well Construction - GW1_20230511

' n'r,L_t_,LU1Nb i±CU 1:11U.1N RECUR') (GW-1) I For Internal Use Only.. • •
1.W ontractor Inf -mation:
. •14:.WATER ZONES;'. r • ._•'..... •• .: .
Well Co ,tor ame • _ FROM TO DESCRIPTION
` '4 —/Lf/j ft ft.
r ,. -
r. ft ft.
NC Well Contractor Certification Number
., •
15:O u t'LR:eASIlNG,(foc multi=rased wells)012 LINER( aP lirahlc)' ;:;`: ;
Morgan Well& Pump, Inc. - FROM ....'. METER• DIA THICIO'ESS MATERIAL
Company Name +1 ft' I ft 61/8/ in' sdr221 pvc
4�A • 16:INNER CASING OR•I'u2i) G.'(4eotfier'maI'cIo'sedlo6p):.:.;'''•>' '.•:l- ;,:•'•...
2.Well Construction Permit#: (�.1.)�� FROM TO DIAMETER THICKNESS MATERIAL"
List all applicable well construction permits(L e.ElIC)County,Stale, a:iance,etc)• ft It . in.
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3.Well Use(check well use): ft ft 'n
Water Supply Well: . 17:SCREEN',.1.,:..::,:t:...-. /t--'••_•:'--: .,:'r:..'-•:::::', .f,.".:.:;1:.it.7',!...:!:.:.'...,•":' .;.-
FROM TO I DIAMETER SLOT Sitar. THICKNESS MATERIAL.
iv Agricultural jMunicipal/Public . ft ft in.
X Geothermal(Heating/Cooling Supply) f jiResidential Water Supply(single) ft ft in.
XiEaust ial/Commercial Di Residential Water Supply(shared) •:18:GROUT. ':. :,' ...-' -
:IrrigationFROM TO MATERIAL EMPLACEMENTMETHOD&AMODIIT
Non-Water Supply Well:
Non-Water ft 20 ft bentonite• poured
Monitoring Recovery ft. ft.
_Injection.Well: -Aquifer Recharge �Groundwater Rem ediation ft ft.
Aquifer Storage and Recovery Salmi Barrier :.�:SAND/GRAVEL P2 CK(if applicable):':.;_.•=':::<:.;:_':: •.. •.;: '.:
tSFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
J Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) DITracer . , :20.:DRILLING.LOG'(attacli'additionals eetki iiecessaryj:•;�:•�_.;
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain she,eta)
r. by ft t� ft-
t rth 4l*
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4.Date Well(s)Completed:'I V7 1 -3 Well ID/ `oft . - ft. '�z �
Q
5a ll Location: 0!�ft 3?) ft• v-y,ti., C— . .
Ie1foki!(`2 11 cy\ � 3-C)ft. 900 ft \v:C; 'So k..t ,, _
• Facility/Owner Name Facility ID (if applicable) ft ft r ! ,tr �' W;' ')
3l� CY- ki is_exi L tt ft. �I . .
_ y oz
Physical Address,City,and Zip n[7^ ft. MAY 0. 1
`` YJVO 61 .°21i•RFMARifs :-:i - ..._..-' _.- -`r'-:., :' .- - .:'':"',,':
County Parcel Identification No.(PIN) . In#".),p-,`: % - .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/tong is sufficient) 4. -
cation
36LQ' C -N qb, Og54 W . ttgpa,
6.Is(are)the well(s) Permanent or Di Temporary Signar eaVrtified Well Contractor -Dat
B��zing•it form,I hereby certffr that the well(s)was(were)constructed in accordance
• 7.Is this a repair to an existing well: QYes or •No with 15AN.1•C 02C.0100 or 15A 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 421 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 depth below land surface: 00
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multipllee wells list all depths if different(example-3(200'and 2@I00) 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 2 7699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the foam to the address in 24a
-01 `'', f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: u• of J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) . • .
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
` : 1636 Mail Service Center,Raleigh,NC 27 699-1 63 6
13a.Yield(gpm) 1 14 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
typ \���I,A6 the paddress(es) 'above, also submit one cop of this form within 3 ys of
13b.Disinfection �(� 11 r Amount: �� completion of well construction to the countyhealth de artment,of the'county
where constructed_ `l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources • 1 Revised 2-22-2016