GW1--03831_Well Construction - GW1_20230609

• . rv.OJ..' J k..V1taiJCul.11UIN IU!CUKD ((-W-1) ForinternalUse Only. •
1.W ontractor Tnf -oration: '
•14:.WA1'Lrlt ZONES•;'. :_
Well Co for ame FROM TO DESCRIPTION..;.•:.::
' -4 - -A , r ft ft
fJ/(/� • r
ft ft
NC Well Contractor Certification Number _
t • '15;Oul'k;It:C4SING,(fai•multi-cased wells)ORPIKER(inapplicable)' ::::'.: •.-._
Morgan Well&Pump, Inc. - FROM TO' DIAMETER' • THIClC1RSS MATERIAL
Company Name +1 �� ft 6118/ 1m: sdt21 pvc• •
33'b3C�g 16: l RCASINGO12-tu1tING:(�edtlie'rma7"closed-lode)?.(::'-'•_- t; ";_':-.
2.Well Construction Permit#• FROM TO _DIAMETER' TRIMNESS MATERIAL'
List all applicable well construction permits'(ta WC County,State,Yarumce,etc)• ft. It . in. '
3.Well Use(check well use): m
Water SuppIp Well: FROM TO DIAMETER SLOT SIZE THICKNESS rMATERIAL.
DAgucultural �u Municipal/Public ft ft. in.
0Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) ft - .- ft in.
0Industaal/Commercial UResidential Water Supply(shared) ;;18-GRODT•:... :. '--r"`"'::•::- •
Irrigation . FROM TO .MATERIAL EMPLACE1 NTMETHOD&AMOUNT
Non-Water Supply Well: • 0 ft 20 ft• bentonite poured
Monitoring JRecovety ft. ft.
_Injection-Well. -
Aquifer Recharge t Groundwater Remediation ft
t.79:SgND/GRAVEL'PACK(iif applicabre) •=':::-..::_.':r t'._'•:In••••.. :--''
Aquifer Storage and Recovery DSa l;n;ty Bather FROM TO • I MATERIA7. • EMPLACF EMT METHOD
Aquifer Test J]Stormwater Drainage ft ft• •
Experimental Technology 0 Subsidence Control ft ft.
Geothermal(Closed Loop) 0Tracer . , ••20.1DRIt NG.LOG'(attl iditiorialslieetsiffieceisaazy"7'fe-i.t-i .
Geothermal(Heating/Cooling Retum) OtherFROM TO n�TI�(color,hardness,eoil/rock type grain s ze efe)
(explain under#21 Remarks) 0 ft `C �
sI'3�( 3renJ 4.Date WeIl(s)Completed. ID# �Sft !) ft. h
0:Location: �.�ft 65 ft. � � �
V Rk� (Q5 ft. �t0 4r. ra��
Facility/Owner Nam Fact& ID#(if plicable) r.("T d"'f.p 1 r r'
Physical�1�Address,City,and Zip ft ft • lUN Cl 9 7073
County
) Parcel Identification No.(PIN) ltlfp{7RCA:f^^►f1 f.^^- ' Un
a'
DW1.iiit 14.•e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lot/long is sufficient) 2 cation:
35.sr.ars "N Vb •4c -3 W 4' t -3
•
6.Is(are)the well(s) fPermanent or DTemporary Signa e f rtified Well Contractor •Date
B o ring is form,I hereby cert fy that the wells)was(were)constructed in accordance
- 7.Is this a repair to an existing well: DI Yes Or IlliNo with 154 N C 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a •
gilds 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 t121 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.
ririlied: . - 1 a fSUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: `.3 � (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdii erent(example-3@200'and 2(100) construction to the following.
10.Static water level below top of casing: J v (ft) Division of Water Resources,Information Processing Unit,
IErwater level is above casino 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
�—(} t ( above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: o "r J
construction to the following:
(i.e.auger,rotary,cable,dsectpusly etc.) •
•
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
11636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a Yield(gpm) Y 0 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 type lr`04 _ Amount: is 4Z completion of well construction to the county health department of the county
where constmtted
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources• • 1 • Revised 2 22 2016
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