GW1--03820_Well Construction - GW1_20230609

1.W ontractor Information: - r
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•14:.W:&r. kt.ZONES:'. - ...1'!.• r
: •.,...... ...._:.:, ._• .
Well Co for ame
t FROM TO ➢ESCRIPTION
•
- 4 �„ — n , r ft ft
• ft ft i
NC Well Contractor Certification Number
k • '15:O U1:8:1t,C?ASING,(fo"r multi=i6sba wel1c)OR LIN II-(ifap licable)'v ::::.::' ..
Morgan Well & Pump, Inc. - FROM T DIAMETER THICIL ESS MATERIAL
• Company Name +1 ft. ft. 61/el in' sdr21 pvc
7 16:NisaR COIN 012.1'UBING.(geothermal closed-loop):..:.;" -t::••••':•.r : .
2.Well Construction Permit#: ) `\ FROM TO DIAMETER THICKNESS MATERIAL' .
List all applicable well constructionpermits'(r.e.UIC County,State,Variance,etc.).' ft ft. . in.
3.Well Use(check well use): ft ft in.
Water Supply Well: . 17."SCREEN'.: :f:;. .`�.••.:•_•.:_:.:: •,-•s_:%', ;..;%,•:;:-.i:• ;•....•.:::' .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
*Agricultural riMunicipal/Public ' • ft ft. in.
.. •Geothermal(Heating/Cooling Supply) i'Residential Water Supply(single) ft . - ft - in.
•Industrial/Commercial pi Residential Water Supply(shared) ,;YB:GROD'T•..." _ . : • : .
r:Irrigation . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: o ft 20 ft bentonite• poured
Monitoring DRecovery ft. ft.
injection.Well: -
ft ft.
Aquifer Recharge 0 Groundwater Remediation , _. . . -
Aquifer Storage and RecoverySalmi Barrier '•1•SAND/GRAVEL'PACK(if applicable)•':.;_:: ,:�:..,._'•...•. •..r •' :
q g D ty FROM TO • MATERIAL • EMPLACEMENT METHOD`
Aquifer Test • jo Stormwater Drainage • ft ft. '
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer . , :20.DRrLrrlNG.LOG'(attacli additional sheetsf aeces'sasy)':i; '•=-
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,l •hardness,soil/rock type,grain size,etc.)
r I ` C.� .ft t tTY( \ ( \Y
4.Date Well(s)Completed + (`- V Well ID# l5 ft• " ft. h
Sa Well Location: �S ft 1 ft' k\uC�i r\ -tt(-4- +—(.,," g .
ft ft ' w 17
�,.9.s.
Facility/Owner
ner a r J FacilityID#(if aPp applicable) ft. JUN V 9 2023
A �1( Wlt ,s 2gt� ft ft.
.
Physical Address,City,and Zip f� ft. ft. (}t! �
C.)N t O :.1112Y-miSRKR=.•.... ;:' :-:i .._ -. . :. :-_.-, : . .....
County Parcel Iden'-cation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 cation' •
C7eCf a� N ` b W C:siftp... ____
a
6.Is(are)the well(s) Permanent or oTemporary Sign e f rtified Well Contractor •Dat
B ping is form,I hereby certfy that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: �'Yes or •No with ISAN 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 ofthis 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-I is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: • I1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: •
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different erent(example-
le-3@.200'and 2(4;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.Borehole diameter: 6 (in.) - 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: d above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(r.e.auger,rotary,cable,directpush,etc.) • • •
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 Supply&Infection Wells: In addition to sending the form to '
typer��� •_ /�6• theoaddress(es)nof 'above, also ion to one f thispar within 30h days ty
13b.Disinfection kb1�/� Amount: ' ( completion of well construction to the countyhealth department of the coon
where constructed.
• Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016