GW1--03905_Well Construction - GW1_20230609

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vr.C,J-j UUIN iIJCUU11U1N RECORD (GW-1) For Internal Use Only.. • .
1.W ontractor Inf -mutton: '
r' ri
14:.WATERZONES:'. -.... : ,„.::::.. • :.... •_ .,. ':
Well Con for ame • ' - FROM TO DESCRIPTION
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ft ft
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NC Well Contractor Certification Number
'15:OU;l'aR PASING,(fot mnlfi=easel walls)O,.t L NER Warp'lirahlr)' ;-:;'.,•:'•. ._
Morgan Well&Pump, Inc. - FROM TO' DIAMETER THICKNESS MATERIALL
Company Name +i ftfi 1/S/ in. sdr21 pvc
tq 16.:7NMER OR..u,JB311G:'(geotliermalci6'sed-loop):.; "-'•_' ::;•,•:.2':•.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL .
List all applicable well construction permits'(ie. VIC,County,State,Variance,etc.)• ft• ft• . m' '
3.Well Use(check well use): ft ft• in.
Water Supply Well: . 17-SCREEN'..::..••:s:;- .' '..:-`_•::',:: ;,.:•.:,-.:4--i;. :::.:.::::' ..:,-
FROM TO DIAMETER SLOT SIZE THICKNESS IYIATERIAL.
Agricultural DMunicipal/Public • - ft ft in.
y i Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft • . ft in.
?ndustrial/Commercial Residential Water Supply(shared) -
�^h ::18:GROUT.:•: ••:: = •:.- :r•p.•-c•';:,'= `-."-::•• .;:..:,...,;- -:,..
hhrigation . FROM TO MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite• poured
Monitoring DRecovery ft. ft. •
Injection.Well: - 0
�--� ft. ft.
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L.)!AquiferRecharge Groundwater Remedial-ion ' -F..-• ,
hAquifer Storage and Recovery Ss Unity '9•SAND/GRAVEL•PACK(if applicable).':.. _':,:-:.;._ -: . .
• ty Barrier FROM TO - MATERIAL • EMPLACEMENT METHOD'
l_'IAquifer Test • DStormwater Drainage • ft ft. '
I Experimental Technology D Subsidence Control ft ft
I!Geothermal(Closed Loop) Tracer . , :2D•DRILLING.TOG•(attacli additional sheefsif neces'saryj'; ::'=s -_
•1_Geothermal(Heating/Cooling Return) ,Other(explain under#21 Remarks) FROM TO DESCRIPTION(color;hardness,soil/roektype grain she,etc)
d.ft.
\t) ft dAr A r L
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4.Date Well(s)Completed 5 I\es fL L Well ID# 10 ft 'SO it h Yro •
ft. � f k kU eCOOM/ S �- •• Sa.Well Location: '
L . ( ^� ft• ft :
Facili /0 rName \``/ t ft.
B , ty FacilityacilityID#(ifapplicable�)(
l..(GC)� w-,:v.e. -,A, �� j�1 V( ft ft. - •
Physical Address,City,and Rio ft b"4 M"d"`r`` 4 f's—
� CasOa SvPc ZI:RFMARTCR=,Cr.;'-,:: •r�r- ra'.:} 4d.,a• ii',-'(}'.q:�. ,•o-d: 4.:'.:.C-:::
. ::-=:.
County Parcel Identification No.(PIN) Jl U y`IIY l„ ` Zr 3 .
S-b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V •
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(if well field,one lat/,l1ong is sufficient) 2 , .cation: r tiOrl PtoC40114N�,{ttx
S 1354 N �O l52- W 2�--�— cyr 5 P` -z 2ti3
6.Is(are)the well(s) (Permanent or ©,Temporary . Signa,re IFrtified Well Contractor .Date
B/aing-is form,I hereby certD5.,that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Dye's or •No with 15ANA•C 02C.0100 or ISA 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 ski record has been provided to the well owner.
repair under 101 remarks section or on the back of this form. • 23.Site diagram or additional weII 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. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled • SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: Vkc (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths indifferent(example-3@,200'and 2(l00') construction to the following:
10.Static water level below top of casing: SO (ft) Division of Water Resources,Information Processing Unit, •
If water level is above casino use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection'Wells: In addition to sending the form to the address in 24a
12.Well construction method: kr above,also submit one copy of this form within'30 days of completion of well
construction to the following:
(Le•auger,rotary,cable,directpush,etc.) • • •
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1 63 6
13a.Yield(gpm) SC) - 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�� 1rb�6 Amount: la D7e completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . , . Revised 2 22 2016