GW1--03314_Well Construction - GW1_20230512

n'r,1jtj I- UINb1tCUt 1J-UA ku-;CORD(GW-1) For Internal Use Only..
1.W ontractor I& -mation:
� I i
14:.Wd.TER ZONES,". .: :• ':
Well Con for ame FROM TO DESCRIPTION
ft ft
r
t e ft ft.
NC Well Contractor Certification Number
15:OUTER--CASING,(for multi=taseawells)
Morgan Well &Pump, Inc. FROM TO' i I DIAMBTER' THIC]�i ESs ATATERras
Company Name +1 ft• ft 61181 'm' sd,21 pvc
Cbbbb� I IS.`Rom C'A SIX6 012•TM1149.(•eot3ermaZ
2.Well Construction Permitt ` FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construcdonpermits rLa WC,Corauv,State,Variance,etc.)- ft ft in.
3.Well Use(check well use):
ft ft. in•
WaterSuppIyWeII: 17.-SCREEIQ',:r. .:::_:. .'� •._•`::':=
FROM TO DVJAWrER SLOTSIZE TATCKNESS hIATER7AL.
Agricultural �Muaicipal/Public ft ft- in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
17^ndusiriaUCommerci.1 i Residential Water Supply(shared)
GROUT-.* - _
hzi ation FROM TO ,MATERIAL — EMPLACEMENT METHOD&AMOUNT
Non WaterSupply Well: 0 ft 20 ft- bentonite- poured
Monitoring DRecovely ft. ft.
Injection.Well: Of
ft ft.
Aquifer Recharge Groundwater Renediation _
'Aquifer Storage and Recovery KISalinity Barrier 'FROM D/GI2ATO PAS
__ MATERIALe I. "•E:I�LACEMENTiMETHOD•- `.
—I Aquifer Test OStormwater Drainage ft ft.
gExperimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) QlTracer :20.DRILLING.LOG'(attacli'sdditi6-sl slieetsifneeess "j': =s 's • : ;:'::
Geothermal(heating/Cooling Return) -�Other(explain under#21 Remarks) FROM T'O h DrrESCRIPTION(color,hardness,soillrock type grain size etc)
s .ft .2 ft {ti
4.Date Well(s)Completed•T�-9—' O Well IN 2A• ft Ileft.
V_ ft ft
Sa..�Well Location: Vic
-t �/
-�- J 1J Y1rJ I ft ft v i
Facility/Owner Name Facility ID#(ifapplicable) ft it
ft ft.
VA
Physical Address,City,and Zip •^'r /V��1 ft ft MAY 1 N 2023
' -
county Par�el Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(iiffwweelll field,one lattlong is sufficient) 2 er cation
3S� L� N 90 e On 1. W
6.Is(are)the well(s) Permanent or OTemporary Signa e f ' ed Well Contactor Dat
B Wing is farm,I hereby Certify Char the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or *NO wuh IS. C 02C_0100 ar IS.4 NCAC 02C•-0200 FPeli Construction Standen ds and that a
Iftbis is a repair fill out Imown well cons6•ucd n information and explain the nature ofthe copy ofthis record has been provided to rhe.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 I GW-1 is needed_ Intricate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: '1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: --Ti—� (ft-) 24a. For All WeIIS: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffer ew(erample-3 a200'and 2@100) construction to the following:
10.Static water level beIow 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.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12,weIl construction method ! 0.�y-( above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(ie.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
,�y� the address(es) 'above, also submit one copy of this fomr within 30 days of
13b.Disinfection typ� Amount: ®� completion of well construction to the county health department of the county
where construtted.
FormGW-1 North Carolina Department of Environmental Quality-DiAsionofWaterResources l i Revised2222016
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