GW1--04340_Well Construction - GW1_20230707

• . YY XJ-J--,l_.:l.J.LN III-U u iluN kUdCO1W (GW-1) For Internal Use .Only:. • ' . •
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1.W outs-actor .In! ation: ' ,
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- . •14:WA_Mt.ZONES-C. ... .'.'-.•.* .: :.1. •...;.•:.::'.'.:';...•'.'•••••••••••••:--. .:/•..... ......':-...':•
Well Co tor ame • • • FROM TO DESCRIPTION
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NC Well Contractor Certification Number . •
k - • s'15:0 LI.T.KN.:CASING,(foi'naulfiZrilioefi..-ivells)Ogloll/TER.(icaP'licable)ii.;::-..:..:::.:.*.'•;
Morgan Well &Pump, Inc. - mom pto.., DIAMETER I- TERCIMESS MATERIAL
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Company Name 6 1/8/ in' sdr21 pva•
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2._,..„c......-0.• 16:ININIER CABDTG OP:•.1.wilista'aecith'efiliaTailise.a.-16'dji)L.f:...--''•• ••i:.;f'-'.',...:."...-.
2.Well Construction Permit 4: Li •._., k,...)--% FROM TO ID-AM-MIR THICKNESS MATERIAL'
. List all applicable well construction permits'(ie.VIC,Counts',State,Variance,etc). ft. ft. .
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3.Well Use(check well use): . ft. ft.
. Water Supply Well: • . . 17.-ScEEDN'..:.,:..:;,:i-.., .•'•.:„.-.. ....:.--;.•.:•':r:i.•'•-•:::::::"...i- .r'f.-:•:-........:-.•' .:,"
FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL.
Agricultural 0Municipal/Public ' ' ft. ft. in.
•:, Geothermal(Heating/Cooling Supply) 2.''Residential Water Supply(single) ft • in.
- dustnal/Conimercial • LA/Residential Water Supply(shared) ...,18...calouT........ .t.....,.•,.„-.....,,..?...•:...,.._..,-...-_-_...-..-.. , ,...-.7:•-. ...,-'•,-''..r.-;;;;-_,`'-',:f•'.••
!Irrigation . . FROM TO MATERIAL EMELACEMENTNIETROD&AMOUNT .
Non-Water Supply Well: o ft- 20 ft• ben ionite• poumd
Monitoring DRecovery • ft ft: . .
_Injection.Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Geothermal(Closed Loop)
0 Groundwater Remediation
DSalinity Barrier
• nStormwater Drainage
D Subsidence Control
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DTracer • . ,
t i Geothermal(Heating/Cooling Return) ri Other(explain under trl.21 Remarks)Experimental Technology ..
ft ft. . .
-19:SAND/GRAVELTA:OK(if i:131ilich.bre).-:'.::,.. •''':;.'-i.-.. .._'•:.•••......1.-.!"...'•'...-:',',..i'..:•••
FROM TO •
• ft.
ft. ft. MA. MILL ' .
ft. EMPLACEMENT IVIETHOD
:20.TaILLEENG.LOG(attiElfallditithial ifieeti..if iii-CeFs'irSilf...V.-•''..':j..,. :4.'•••-:-
FROM TO DESCRIPTION(c lorihcalcrElness,soil/rock type,grain size,
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4.Date Well(s)Completed:len 19 ) Well ID# .... .ft. f'S - ft. • ° • . ‘ V.,.
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_..5a.Well Location: __ . rt. 311) ft• -ue, 0 Inurv*if,
Vfo'cs 'ct- . ft ft
Facility/Owner Name Facility 1D#(if applicable) •
ft. I ft
4S\1Z) ' A Illurof,OArysitf,V41, vqty *,11, Xtlt4 ft.
strol .
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r':::.r''.LP i:::ft V ''' )
Physical Address,City,and Zip ft.
V.4)1VI OY' • Cr-/.
•'-2:111E1Vall-TCS'f.:.-fi.-::,;:--':-7.-.-.Z:.l.Z.':....: iiiii .,...:.?.--'..-' ,.,:::.•-?: ::'4.s-1,-....All::::. .
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County Parcel Identification No.(PIN) t1-1:-3:7.-':..':`•1 .-..'r!‘,..,:az.-‘,..3 1
1:::woiniD
5b.Latitude and:longitudeG in degrees/minutes/seconds or decimal degrees: • . . .
(if well field,one lot/long is sufficient)
di•C.2.ti
'N 0 XI:2:2) •
730( s ct(I)t CgO. sci-0-7S ? W - . .. .
6.Is(are)the well(s) Permanent or DTemporary SiDaa,r Frtified Well Contractor •Datl
B hang is form,I hereby Cerit5,that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or *No with ISA N. •C 02C.0100 or ISA NCAC 02C..0200 Well Construction Standards and that a
Ifthis 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 P.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 OW-1 is needed. Indicate TOTAL NUIVEBER 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: 2...cto ( t-) 24a. For All Wells- Submit this form within 30 days of completion of well
. For multiple wells list all depths frlifferent('example-3@,200'and 2@,100) construction to the following:
10.Static water level below top of casing: 40 (ft-) Division of Water Resources,Information Processing Unit, • • .
.. .Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) • 24b.For Infection Welts: in addition to sending the form to the address in 24a
12.Well construction method: at.IP i
above, also submit one copy of thi form within 30 days of completion of well
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.(i.e.auger,rotary,cable,directpush,etc.) construction to the following: • • •
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 17 • Method of test air pressure 24c.For Water Supply&Infection Wells In addition to sending the form to
i . the address(es) 'above, also submit one copy of this form within 30 days of r,
13b.Disinfection typerlf\100)/VC, , Amount: 111-0 2.. completion of well construction to the county health department of the county
where construbted_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . I. Revised 2-22-2016
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