GW1--03910_Well Construction - GW1_20230609

YYL'LL l:UIN/It(UC11UIN RECORD (GW-3.) I For Internal Use Only:. •
1.W ontractor Inf -motion: 1
.t
• •14:.WATER ZONES•.'. . • :_ .... .. • • •._•- .-- ..• .....
Well Con for ame _ FROM TO DESCRIPTION
• ' -42- r A , r
t r t ft ft
(fif7� ft it
NC Well Contractor Certification Numbet
.; '15:Oul'k;It..GASING,(iac multi=cased wells)ORESKER(if ap licahle)' ::::'.I.::'-• --
Morgan Well &Pump, Inc. . FROM TO' DIAMETER THICKNESS MATERIAL
Company Name +1 ft• "Ck ft 61/8/ rn' sd21 pvc
�+ �^ G J Oh�`^ 1alEN IERCASINGOE•iuBU G`(gedthernnal'ciosedloop)L(:.•"='•;' :-6 • .
2.Well Construction Permit#/: J 1- r. V ` d� FROM TO DIAMETER THICKNESS MATERIAL- .
r
List all applicable well construction permits'6.e.NC,County,State,Variance,etc.)• ft ft in.
3.Well Use(check well use):
ft. ft. in
Water Supply Well: . 17.SCREEN'.=..;.:t_,. ..._...-••=•=• 1:;-:-r!:..i-• '.::-;,,:_..:•::; /.- :;•.:.--::1
.:.-
FROM TO DIAMEtbit SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipaUPublic ft ft in.
1 Geothermal(Heating/Cooling Supply) :'IResidential Water Supply(single) ft • . ft in. •
IndustriaUCommercial 01Residential Water Supply(shared) =_:,• :.
::18:GROUT•::.".:. _... • .
l Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery - ft ft •
-Injection.Well: -
Aquifer Recharge 0 Groundwater Remediation ft ft.
•1_9:SAND/GPAVEL'PA.C1C(if applicable) _•'.:: =.:: --`•- . - ',.
Aquifer Storage and Recovery- Salinity Barrier FROM TO • MATERIAL. • EMPLACEMENT METHOD
Aquifer Test ElIStormwater Drainage ft ft
Experimental Technology D Subsidence Control ft ft .
Geothermal(Closed Loop) 10ITracer - , :20.DRILLING.LOG-(attach'additi*criailslieets•ifueces'sa:rpj':t;�'•:•-.s
Geothermal(Heating/Cooling Return) Other(explain under#21 Remadrs)
V FROM TO DESCRIPTI/4�N(color,hardness,soil/rock type,grain size,etc.)
r. ft l b ft' vta ate
4.Date Well(s)Completed: `' 19( Well m# I t)ft ' ft L _,_ ` .
Sa.SWel1 Location:� r���
• ��� D \- • ► t. bWte• cyOIaM1L
• • Facility/Owner Name Facility ID#(if applicable) ft it
•
C)--`Cjv I.1 V kX V4•Lurcortt4C-,2. 05 ft. ft. .
Lam.. rr`.7- ;
Physical Address.City,and Zip ft ft ►!""' /i..o y' "....:,LI
County Parcelldentification No.(PIN) 3�i1V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "'D;'S'' it
(if well field,one lat/long is sufficient) 2 •
.ration b1
35 • L,`l�3 N •533 W �� (e(o �3
AK
6.Is(are)the well(s)�FPermanent or Q]Temporary
Signa.. 4tiEed Well Contractor •Date
B/rating•is form,1 hereby cettibi that the well(s) was(were)constructed in accordance
- 7.Is this a repair to an existing well: QYes or '.;No with ISAN.!•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 thii record has been provided to the well owner.
repair under#l21 remarks section or on the back of thisfotm.
- 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'ofwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �o (in) 24a. For All Wells: Submit this foam within 30 days of completion of well
For multiple wells list all depths ifdfferent(example-3@200'and 2@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 font to the address in 24a
12.Well construction method L� above,also submit one copy of this form within 30 days of completion of well
d construction to the following:
(Le.auger,rotary,cable,direct push,etc.) \.J - '
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, -
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 a - 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 typerY‘ 10Nee • Amount: 1 Lg 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