GW1--04224_Well Construction - GW1_20230706

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• . vY1',11L l.UINsit(U1:11U1N ktC'C:Uktll"(GW-I) For Internal Use Only.. -• I
1.W ontractor -nation: •
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Well Co tar ame FROM TO DESCRIPTION
A ft. it
ft
NC Well Contractor Certification Number
.` • '15:O ut'Nrit:CASING",(ioc multi=risen wells)OR LII .R(ifap licable)' ::':•:I.•. ..
Morgan Well & Pump, Inc. -"FROM TO' DIAMETER ' • THICKNESS MATERIAL
Com any Name +1 ft' C5 it 61/8/ in' sdr21 pvc•
P
v 16 RCt1SIl�TGO1t.1UBlP G'(�eotlierma1clo'sedAodp):.::. _'<::%'''
2.Well Construction Permit#/: . FROM TO -DZAlvIETER THIcxivass MATERIAL' • .
List all applicable well construction permits7i e.VIC,County State,Variance,etc.)- ft. ft . m' •'
3.Well Use(check well use): ft ft_ in.
Water Supply Well: . 17_"SCREEN - ::. .`:..:.'.. -: . :1-::. :,.: �4•:.7,.: ::•. ' .,
• FROM TO DIAMETER SLOT SIZE THICKNESS TerA1 ettLAL•
Agricultural JMunicipal/Public ' • ft ft in.
i Geothermal(Heating/Cooling Supply) jiResidential Water Supply(single) -
ft • - ft in.
_
-thustrial/Commercial Residential Water Supply(shared) • __.y.�-,:.:•__, .
Irrigation FROM TO MATERIAL EMPL_4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: - o ft 20 ft bentonite• poured '
Monitoring DRecovery ft. ft- .
_Injection-Well: ft ft.
Aquifer Recharge 0 Groundwater Remediation
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:.79:SAID/GRAVELPACK(if applicable) `;; _ ...•._...':'-,
Aquifer Storage and Recovery DI Salinity Bather FROM TO • MATERIAL • EiA:PLACEMENT:ETHOD
Aquifer Test DStosmwater Drainage ft ft•
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) DTracer • . , •-20.DBJILII4G.LOG'(attaclf dditialilifeets. uecessarp)R'.:":=i
FROM TO DESCRIPTION(color,hardness,soiltroek type,grain size,err.) ,
(Geothermal(Heating/Cooli//ngReturn) ��Daher(explainunder#21 Remarks) ft IS. it, b���
4.Date Well(s)Completed:(M I r1 L d'� Well TD/ 15• ft 15
3 ft. brawl
35 ft. SS ft S0 (vk -
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Smell Location:'`?6 ]�
9 byJ , \\ Y ` .. 55 ft. `6�ft bwUr_ hl .) .
. Facility/Ownk Name Facility ID#(if applicable) ft. ft
\°�S� -S rs madj NC 20 G ft ft. P E.;C E a°t 1 =D
Physical Address,City,and Zip ft ft
County ParcelldentmcationNo.(PIN) •
Intcac,4ion ;Jrc•M•J i:v, Lji.4
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • :"t`':t` ' �
(if well field,one Milton'is sufficient) ®�� 2 cation •
�5� �� N (XJ t. � W 1 VI i6.Is(are)the wells) Permanent or �ITdmporary Sigma f rtiled1.....„.....).
Well Contractor .Date
B ning is form,1 hereby cert 5 that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well: 0•'-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 of this record has been provided to the well owner.
repair under 021 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
9_Total well depth below Iand surface: 400 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
. For multiple wells list all depths y-different(example--�3,a 00'and 2@100') construction to the following.
10.Static water level below top of casing: '1 5 (ft) Division of Water Resources,Information Processing Unit,
,Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1,617
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form 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
J construction to the following:
(_e.auger,rotary,cable,d rectpusb,etc.) • • •
FOR WATER SUPPLX WELLS ONLY: ' Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) 5 . Method of test air pressure 24c.For Water Supply&Infection 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 types 6'lebti,e, . Amount 1 6 62-, completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2 22 2016