GW1--04184_Well Construction - GW1_20230706

• . vvxt.n.,t.v1N6_ LCUl.:11U1N RECORD (GW-1) Forinte;rnal Use Only., I '
•
L W ontractor In' ation: - :.. . • ' '
•14:.WATER ZONES:'. r. • • • :
Well Co [or are • FROM TO DESCRIPTION
ft .
��^ /— r r
NC Well(contractor Certification Number r r ft
_
.i •15.O u'azit:CASTNG,(foc multi-rased wells)bR LITTER(ifap licabla)• .•.f'.•.•_ •-
Morgan Well&Pump, Inc. - FROM TO• DIAMETER , • TBICZtESS MATE3.RAA
Company Name +1 ft. 4(kb it 61/8/ m' sdr21 pvc•
�-y\��� 16-D R CASING OR•1 uBING.(kentlierrma7•r1nsed-lode)1.(:.�''-a' :S%•`- •'• .
\ •
2.Well Construction Permit#: (h/1 � FROM TO DIAMETER TmCE:NESs MATERIAL' •.
List all applicable well constructionpermits'(ie.i/IC,County,State,Variance,etc.)• ft ft. . in. •
3.Well Use(check well use): ft ft in.
. Water SuppIy Well: . 17.-SCREEN.,:.- :f:, •••:: °_.:::•:;:•r1:. :i-',.:ter::;..•;. . .-;•.•..•.;,`.` .::
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public • • ft ft in.
!Geothermal(Heating/Cooling Supply) *Residential Water SuppIy(single) ft . : ft in.
Industlial/Commercial • aiResidential Water Supply(shared) _
::IS:GROUT.: --.r•= _. .--' .
'.Imgation FROM TO MATERIAL EMPIA4CEMENTIr1ETHOD&_AMMO AT
Non-Water Supply Well: - o ft 20 ft bentonite-. , poured
Monitoring DRecovery • ft ft
_Trajection.Well- --
�-,�. ft ft.
Aquifer Recharge '1 Groundwater Remediation : . . :
!.19:SAND/GRAVEL'P9.CI (if applicable)•':.:_: :-:. •_ . r., .-.-
Aquifer Storage and Recovery 0SaIinityBarrier • FROM TO • MATERIAL • EMIAPLACEMENTMETROD
Aquifer Test • OStormwater Drainage • ft. ft
I Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) (Tracer - , :28.DRILLIIIG-LOG'(attacl?dditiorial ilieetkifuecessary')tt.t'•t=s
I Geothermal(Heating/Cooling Return) Mather(explain under#21 Remarks) FROM TO DESCRIPTION(etio,hardness soil/rock type grain size,etc)
4.Date Well(s)Completed:1(e 1,2, t 1a-t Well ID# ��. ft rib ft. . C+)i Al;( • .
•
a.Well Location: i) fc t la) ft r-- ,`"' .,r a ..,,-,
Facility/Owner Name Facility ID#(if applicable) \\.0 ft. k`{,�.Z) 4.r An•.1, J`i! 0 C, 2023
tDD cA� �w rck ( ,4a4e+4Cdt3i • `y-5 f. \o-c ��. r oo t
Physical Address,City,andZi ft a ft Irlr.n 7,..,,v f1 , .. N.;g U
rAtalte-VJaWCAA
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • ,
(if well fieid,one lat/long is sufficient) 2 cation: •
3S,.113$a' 'N %%4 tb W .. .
6.Is(are)the well(s) 'Permanent or DTemporary Signa e f rtified Well Contractor •Dat
Ening is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or *No with ISA N 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 ofthis record has been provided to the well owner.
repair under#2l 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 ifnecessary.
drilled: •
•9.Total well de SUBMITTAL INSTRUCTIONS
depth below(and surface: ��
p (ft) 24a Far All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi•�erent(example-3(200'and 2 a 00')
construction to the following:
10.Static water level below top of casing: t�LJ (ft) Division of Water Resources,Information Processing IJnit,
,Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
y •
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e,auger,rotary,cable,direct push,etc.) • • •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUFFIX WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) 8 • Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to •
f--J• • the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type 6(ttvC' . Amount: 1 bZ 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- . I ' Revised 2 22 2016