GW1--04342_Well Construction - GW1_20230707

• YYM41_1J t:U1Nii 1±CU C:11UJN 10E(,URIY(GW 1) For Internal Use Only:. •
1.W onfractor Inf ation: •
r• :. - .
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• 14:.4yATERZONES: - : :. ._• ,... ,. .
Well Co tor ame FROM TO DESCRIPTION
-4w.— A r ft ft
fJr'(/� r r
ft ft 1
NC Well Contractor Certification Number
., •• '15:0uxEIt,e4SING,(idimulti=rased-evens)Q.RLZNL.(rfaf)Hciblef .•:::•,.:••. --
Morgan Well &Pump, Inc. : FROM TO' DIAMETER i. THICKNESS MATERIAL
Company Name +1 ti• ft 5 10 m sdr21 pvc•
16:INNER.C. OR.TOBING(geothernd1cldsed.loop)'1 ,, .•., :";.` • .
2.Well Construction Permit ii: a-( FROM TO , DIAMETER THICKNESS MATERIAL' .
. List all applicable well construction permits'(f.e.UIC,County State,Variance,etc.)• ft. ft. . In.
•
3.Well Use(check well use): ft ft m
Water Supply Well: . 17.-SCREEN',;:: •�. .`-_; _••`__: .•:-t'.:. -;,:=:_:::;:-= ?.:.•.:::° .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural roMunicipal/Public • • ft ft in.
I Geothermal(Heating/Cooling Supply) t2'rResidential Water Supply(single) '
ft it in.
M1Edustdal/Commercial UlResidenlial Water Supply(shared) ` .
bi lnigation . FROM TO +MATERIAL : . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • o ft 20 rt• bentonite• poured
Monitoring ICIRecovery . ft. ft.
_Injection.Well: -
ft ft.
Aquifer Recharge D Groundwater Remediation . .
Aquifer Storage and Recovery :�:SgND/GRAVEL'PACK(if applicable)•"=.::. _ :: :; :`-'•_.:•:: -•'.
quit g �1SalinityEamer FROM TO • I MATERIAL • EMPLACEMENT METHOD
Aquifer Test OStormwater Drainageft. ft.
I Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer . :20.DRIt lNG.OG(attacli'sddition'il slieets.if'necessary);'.:'-::'•`.'=.i
r.
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain s ze etc)
4.Date Wells)Completed 1 ,)-3 Well ID# ��� r1 �/1
%oft rt. >�.2.}:('h IP OI J k�
S Well Location: /// _ °In fn r ft ' /C ( 1 '�i._ S•s--
ittAiron
Facility/OwnerName� i Facility ID#(if applicable) H' f
cL� �\ PASkV, `4.nnonuttL ( )G 1V) t� ft .II Il.. 02023
Physical Address,Ci d ti• • l n;^"i ,: :,;<r::.) li r'
r't I h k6)1 f' OC: .211u'MAEXS ...:.. .`.t� _. . ..._. _..:. :__,-,.'r.'+• ,_�?::�....... - .
Va
County Parcel Identification No. -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • .
(dwell field,one lat/long is sufficient) 2 cation:
6.Is(are)the well(s) CPermanent or Temporary Signa e f rtitied Well Contractor •Dat
B snug is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or )111No with 15A N C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a •
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remark•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 piovide 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: zoo SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft-) 24a. For All Wells: Submit this form within 30 day§ of completion of•well
For multiple wells list all depths p chfferent(example-3@200'and 2@1009 construction to the following:
10.Static water level below top of casing: i-"{CD (ft-) Division of Water Resources,Information Processing Unit,
,Ifwater level is above casing;use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method Y. _ above,also submit one copy of this form within 30 days of completion of well
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 2769 9-1 63 6
13a.Yield(gpm) 1 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
I �,'^J C • the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ �''/�'+ Y M ' . Amount: Orr_I 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