GW1--04178_Well Construction - GW1_20230706

• vyjml L KC,L, UiNaLul:i1 .K U1N L(.U_ JJ•(GW 1) For Internal Use Only.. '
1.W ontractor Int' •oration: I .
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•14:.WA1.1.R ZONES:'. - .r:.. ::...:, -• .•.--...... :.". _:.-
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•Well Co for ame FROM TO DESCRIPTION
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NC Well Contractor Certification Number
• '15:0 D.ar1t,R A RING,(foi-multi=cised weIls)OR L-IIiER(Tip'licable)%ri- :::::::'• -:
Morgan Well &Pump, Inc. - FROM TO' DIAMETER 1 • THICKNESS MATERIAL
Com an Name +1 ft Cril ft it sd21 ipvc•
P y 1CINNE.RCAMINGOR•lUISING:(geotiieirmaTclosed-lodp)r.(:.;'='•a• ;:-;%.'"..'" -
2.Well Construction Permit#}: .3(`b ,11 FROM TO DIAMETER TaTcravEss MATERIAL'
List all applicable well construction permits"(e.UIC,County,State,Variance,etc)• ft. ft• . in. •
3.Well Use(check well use): ft. ft in
Water Supply Well: . 17_-SCREEN;:r::;.:t= '�...'-._••`_:: s.:.•• :::',:i-;,.:•�,:'' •:r,- •-: :_:'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
jAgiicultural • JJMunicipalIPublic . ft. ft in.
Geothermal(Heating/Cooling Supply) L''Residential Water Supply(single) ft ft in.
I]^ndustriallCommercial DResidential Water Supply(shared) :;18:
hImgation FROM TO MATERIAL EMPL4CEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 ft 20 ft• bentonite• poured
Monitoring DRecovery ft. ft •
_Injection.Well:
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ft f
Aquifer Recharge JCnoundwater Remediation 19:SAND/GRAVEL•PAC C(if aP Picable)•..:.-''•:::`:-:-'': ,"' • '-Aquifer Storage and Recovery DSalinityBarrier FROM TO . MATERIAL • EMPLACEBEENTMETHOD
• Aquifer Test D Stormwater Drainage ft. ft '
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) DTracer - , :20.1113ILLRIG.LOG'(attach`idditton'sislieets.ifrieces'sa ) i • :-;;.';•
I Geothermaleatino(Heating/Cooling RFROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
egehlm) Other(explain under 21 Remarks) 0 .ft +�lJ ft. y-,�d eLA
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4.Date Well(s)Completed:OQ I D� ( Well ID# atSft 1A- ft
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5a•Well Location: LK ft. lb ft. Set •
• OA VI �N®SS .. 7b ftcit) ft AwrnW vn, IrGC,
Faacili`tyy/OwnerNamAe� FacilityID# if a 10 t ft
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PhsicalAddress ft ft City,and Zip Vp�. -�1
- 't� 4�� 21c•RFMARKR::.':':•.:'-:; _- ,•�?s•=�U - ....
County Parcel Identification No.(PIIN) If1i:i,'i .^:='.^,n,'•^:.�_ .
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
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(if well field,one lat/long is sufficient) ® 4.calion: >
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6.Is(are)the wells) Permanent or QlTemporary Signe rre IFrttifed Well Contractor •Dat
B/Knino is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or s;No with 15.4 N•!•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 ofthii record has been provided to the well owner.
repair under521 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 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 Iand surface: 61` ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@,2000'and 2C 100) construction to the following:
`6�0'
10.Static water level below top of casing: J (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: 7n addition to sending the form to the address in 24a
12.Well construction method Q 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.) - • •
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
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1636 Mail Service Center,Raleigh,NC 2769 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
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type' 1�'10� Amount: 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 . -1 Revised 2 22 2016