GW1--03911_Well Construction - GW1_20230609

yv.z. L UUIN'll.x(UU11u1N RECORD(GW-1) ,For lntemaIUse Only.. '
1.W ontractor Inf •mation: '
•14:.WA.TERZOIES•:'. ..•r -• .: •.,..,:. ....„:.:, :.-
':
Well Con or ame ' • FROM TO _DESCRIPTION
L—v —A , r ft ft.
f
r ft ft
NC Well Contractor Certification Number •
.l • '15;OU;t.b1R:C.SING,(foi'multi='rases Swells)OR LINER(ifap lica'hle)' :".:.:;'•. ._
Morgan Well &Pump, Inc. . FROM TO' DIAH� TRIMNESS
TER THINESS MATERIAL
+1 ft. Q ._ ft 6118/ m' sdr21 pvc
Company Name
��•�•V 1�J✓•y � ,.,. 16, RCASS]NGO12.xviiNG: eother'tna7ciosed.-lo6p):.i::;"'- _' ''':.*'1..
2.Well Construction Permit#: G/ FROM TO DIAMETER THICKNESS MATERIAL' •.
List all applicable well constructionpermits'(ie.ElIC,County,State,Yatiance,etc.)• ft. ft. . m' -
3.Well Use(check well use): ft ft: in.
Water Supply Well: . 17_'SCREEN' ::<.:'::. .`•...,-•., .:.1.:''-'t:. :i-;,.:'.;,._:::.mot.-<::'.:. :::' .=:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
DAgricultural DMunicipal/Public . ft. ft. in.
Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) ft • . ft in.
I rndustria1/Commercial ]Residential Water Supply(shared) _-:r• ,.:.
::78:GROUT::.
E Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&-AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
Monitoring Recovery ft. ft.
_Injection.Well: ft ft
Aquifer Recharge DI Groundwater Remediation
•.-9:SPND/GRAVEL'PACK(if applicable)-- ;:.i.= '
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO • I MATERIAL • EiYPLACEMENTMETHOD
. _Aquifer Test DStormwater Drainage ft ft. .
Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) alTracer . .28.DRILLIIQG.L'OG(attacli'sdditionaliieets.ifneceibir)'':`: '.." :..
i Geothermal(Heating/Cooling Return) nI Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
ti ft ft vy I .
4.Date Well(s)Completed:tc�t.1� Well ID# ft- ft- bi 'A rie
5a.Well Location• tb ft nD ft �7You1 1($ ,�.-
" t . . ' •
��Da li'"1 • O ft �J�0 ft -bwre.+ tQar4 a
Facility/Owner Name Facility ID#(if applicable)
/ ft ft
�3Aa-�� S j ` q r�i leq,�+ ft ft
P ysical Address,City,and Zip ft ft.
•
:. .`_., -_.
County Parcel Identification No.(PIN) , es . tea, ?�''" ,o.w r. .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "m .-t-s°tL—4 4.m Kam:`
•
(if well field,one llat6ong is sufficient) �y 2 e cation: J, r iV i r V, f� •ZO ry
'SS,3429� N �0 ��Qc b W � r7 L
6.Is(are)the well(s) Permanent or )Temporary Signs.a lir rtifed Well Contrac: • CACCOOG Date
Bfgning•is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes, or 's No with 154 A•C 02C.0100 or 1SA 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#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-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: `S (f•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 ,200'and 2@I D0) construction to the following:
10.Static water level below top of casing: lit5 (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
�, k` , ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: U t-/ construction to the following:
(Le.auger,rotary,cable,direct push,etc.) • ' '
Divisidmof Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
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the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: , completion of well construction to the county health department of the county
where constmtted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2 22 2016