GW1--03908_Well Construction - GW1_20230609

vr1n,L1 l..:U1Nb 11[W U 11UNV Kl!X2ORD (GW-1) For Internal Use Only:, • •
1.W contractor I nation:
• ` •14:.WIs1'EK ZONES•.'. • r;•: •..
Well Con for ame • FROM TO DESCRIPTION
- t A r f
~ t ft f.
NC Well Contractor Certification Number
., 15:O U1'k t,CdSINts,(fo"r rnniti=rased 4vells)OR IIItER Warp.licahir)'y;:;':; d
•
Morgan Well &Pump, Inc. _ FROM TO' DIAMETER THIcIMESS MATERIAL
Company Name •
+1 ft. �1) ft6 1/8/ in' sdt21 pvc
r��qq
• `]M 16, ER CASEDR O ..CUr3ING.(geothecrmal•dfised-lodp)L:':.:"` `:•;'• • :'
2.Well Construction Permit F 2��f a2,—rzr)C(ri FROM TO ,DIAMETER THICKNESS MATERIAL' .
List all applicable well construction permits'(ie.UIC,County,Stale,Variance,etc.)- ft ft. . m'ft ft: in.3.Well Use(check well use):
Water Supply Well: . 17.SCREEN',:• :f:,. ._�<-•-4•`_.= •i::.4 : , :-;,.: :':=.::. b.'„,:;'.:.•.:::' .:,-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
*Agricultural DMunicipal/Public ft. ft in.
:�Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft • - ft in.
*Industrial/Commercial ]Residential Water Supply(shared) • _ :.-r-,;.1:,,,:x=..:.•-
Ilmgation FROM TO MATERIAL ENTLACEI,ENTMETHOD&AMOUNT •
1 Non-Water Supply Well: a ft 20 ft. bantonite- poured
Monitoring DRecovery ft. ft.
_Injection.Well: -
�—,� ft. ft .
Aquifer Recharge f Groundwater Remediation •79:SAND/GRAVEL'PACK(if applirabre) _.'•:::-:.;._.•::•. -...:•-•, .; '..;•-:•',- `::.-
Aquifer Storage and Recovery D Salinity Barrier FROM TO - MATERIAL • EMPLACEKENTMETHOD
I
Aquifer Test kl Stormwater Drainage ft ft•
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) nTracer . , :20.DRILLltiG.L'OG'(attachsddition'sl slieetsif aeceil ryj;:: l:'•i. '.`'•l;_'c:•_
r.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
b .ft.
l< ft re..1A a"f-k.: •
4.Date Wells)Completed.:51 l4:6 1 Well ID# \c . ft. 36 ft b ,Ax., .
5a.Well Location:Loc�a_tioen� (1 )� 3C�0 ft SD ft _bi j i' rjj C.jC . • • •
ffClr l �``�5. 1.�0.YW mCf+ ` 6 ft G15 ft IL rAyilirtle
Facility/Owner Name FacilityiD#(ifapplicable) b/5 ft '1515 f" ?
5°►�� C�o�rl D1 Ikc- sl S 6Qtos iDl>JL
Physical Address,City,and Zip • ft fr. a.
y"�Cl-JfX�JI__ .^l Uc `21i-uIMeRK.0°:.-C':°.:-' bY'>'...'.::::. ram. N -.;,
County Parcel Identification No.(PIN)
JUN t, 5 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is suincient) C/ p
35,` 6N5 .N<zb 4G 5G • W z , .ction: �
2.______?inforonation
MPOG
5 - a3
6.Is(are)the wells) Permanent or D Temporary Signa.� rtiSed Well Contractor •Da
B/mrinoP•is form,I her•eby'certify that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well: ElYes or *No with 15A NA•C 02C.070D or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature of the copy ofthii record has been provided to the well owner. •
repair under i721 remarks section or on the back of this fomn.
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
9.Total well depth below land surface: p bl45 • (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths Ifdiier•ent(example-3 a(200'and 2@100') construction to the following.
10.Static water level below top of casing: St) (ft) Division of Water Resources,Information Processing Unit,
,Ifwater level is above casing 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
1 -[ ai, j I _ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: e J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) - • •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gym) l� Method of test air pressure 24c.For Water SuppIv&Infection Wells: In addition to sending the form to
/ the address(es) 'above, also submit one copy of' this form within 30 days of
I3b.Disinfection type �'r�N{j Amount: 1p GZ completion of well construction to the county health department of the county •
where construbted-
Form GW-l. North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22-2016