GW1--04185_Well Construction - GW1_20230706

• . YYit LL LUlVJ A±CUU11UIN_RECORD'(GW-1) Forintemal Use Only.. . •
1.W ontractor Inf. Lion: 1 ..For
,
• 14:.Wd1'�KZOIlES .-
Well Con tar :m FROM TO DESCRIPTION
- 41.- , r ft
ft ft
"JJ�(/� + t r ft
NC Well Contractor Certification Number •
� '15:O UIPiR,CASI2 TG,(ioi•multi=rasea wells)OR L�TER(Tap licable)'=1 :f`...'.11.•.
Morgan Well &Pump, Inc. - FROM TO' DIAMETER • LeWII NESS MATERIAL
Company Name +1 ft s V ft 6 10 in. sdr21 pvc•
2.Well Construction Permit#• �0`l, J `�- FROM CASII�TG072•lUDIAMEWeRlierma7'I a LESS r.':.:"'••;' %r''
- FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits'(Le.UIC,County,State,Variance,etc)• ft ft. . in. '
3.Well Use(check well use): ft ft in.
Water Supply Well: . 17.SCREEN',.: :_,. .`..:••._•=:. .:::::. :,.'.:•:;:: :..r• r.:. ` .
Agricultural• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft • . ft in.
Eaustrial/Commercial • (Residential Water Supply(shared) .'18:GROUT,':•" =:''r'`-•':;
�1•'.Inigation FROM TO MATERIAL EMPLACEMENT METHOD'&AMOONT
Non-Water Supply Well: o ft 20 ft bentonite• poured
Monitoring Recovery - ft. ft. .
Injection.Well.; ft. ft.
Aquifer Recharge D Groundwater Remediation
Aquifer Storage and Recovery :.19:SAND/GPAVEL'PACK(if applicable)•".!_:-•:;:: •_'•:;•.-•."'-`•''...:•,'-:,..•`-:•
Q g ry Ell FROM TO • i MATERIAL • EMPLACEMENT METHOD
Aquifer Test • IStormwater Drainage • ft. ft.
Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer • . , :20.DRILLINGLOG•(attaclradditiorial ssieets •aeces-sary')''_S;
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
rb •
ft lb ft• ft.a cL
4.Date Well(s)Completed:(Q,(,t 4-i 1)-3 Well ID# f 0• ft � ft. f0w� `, . •
•
5a.Well Location: gizifeaitit-
ao ft SS itYOW r r6(, : •• -Ae.Sb xv\ •• 5,5 ft. d 4-=.ft \utd eetkINc, -e. •
• Facility/Owner Name Facility ID#(if applicabl ft ft
k(oGob GA, r ex fir► .0\td applicable)
o1 ftft. 7:-`,..._
�I�- �:, ; �
ft ft r Yr I rl.....& ?� '1... ._.,e
Ph sitar Address,City,and Zip `'
�,�`,� U :21i•RF.M6RTCC`.f:..;'::.-'.-:i ;. : .} . • z'•d..:•:;..:•':.
County Parcel IdentificationNo.(PIN) J M1 .
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: :,,d:it•
L ii
(if well field,one lat./long is sufficient) 2 cation:
3S.-\�3 -N 10 i5.OiK W �5 ` 3
6.Is(are)the well(s) Permanent or 0Temporary Signa e f rtifed Well Contractor •Date
B ring is form,I hereby car*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or NINa with 15AN C 02C.0100 or 15.4 NCAC D2C: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#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: • S U1IMITTAL INSTRUCTIONS
•
9.Total well depth below Iand surface: l'. )r-S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different erent(example-3g200'and 2@I009 constmction to the following:
10.Static water level below top of casing: 4S (ft-) Division of Water Resources,Information Processing Unit,
Ifwater layer 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 fa=to the address in 24a
1 y, f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: U construction to the following:
(Le.auger,rotary,cable,direct push,etc.) • • •
•
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5d Method of test air pressure 24.c.For Water Supply&Infection Wells: In addition to sending the form to
•
t the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ �l`bN�j .'•Amount U C 2. 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 i- Revised 2-22-2016