GW1--04343_Well Construction - GW1_20230707

• YV.L11Lcu1N 1jc.uul'1u1N'RJC01 (GW-1) .For Internal Use Only:.
1.W ontractor Inf 'oration: • '
•14:.WATER ZONES c'. . ... .. . _,. •.- . . • :
' W��ell Co tar e- FROM TO DESCRIPTION '
(np] r { ft
+ ft ft
NC Well contractor Certification Number I
- •15,OU�ER:t1ASING,(fot multi-rased wells)OR TU Z$.(ifap Hcable)' •-
Morgan Well&Pump, Inc. : FROM TO' DIAMETERI • THICKNESS MATERIAL
•
Company Name ' 4-1it 61/8/ !in' sdr21 pvc•
�/ 16:10,KER CAu o12•ruit NG:(aentliermaZ•cIased-loop)?.;:."-'•_ ; ':.
2.Well Construction Permit#: a��"`0,, FROM TO -DIAMETER THICKNESS MATERIAL' .
List all applicable well construction permits'd e.UIC,Catarte,State,Variance,etc.)• ft ft. . m '
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3.Well Use(check well use): it ft• m
• Water Supply Well: , 17 SCRF,E r,::..-:'::. .`:.,.'•.:••`...:_-..:: i• =-,:: ::.::.r..: :;'.
Agr10r11tIlI'al FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
it _Mmnicipal/Public ft ft. in.
•Geothermal(Heating/Cooling Supply) y0','Residential Water Supply(single) ft • - ft in.
•') lnsttial/Commercial p�--;�Residential Water Supply(shared) • _
►=1' 18:GRODT•::•..: =:;� ;'::-::''�c"'`y:=:=•�:•:,•:... ...•_ •:. �..,•-...._• -.
�I•'.lmgation . . FROM TO MATERIAL EMPLACEMENTMETHOD'&AMODNT
Non--Water Supply Well: • a• ft 20 ft bentonite poured
Monitoring ICIRecovely • ft. ft
_Injection.Well: ft ft
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Aquifer Recharge 0 Groundwater Remediaiion •
-
:.19:SAND/GRAVEL-PACE(if applicable) :.:6:•--:;;.-' :_''::••.-•..i `•'12•::"='': C:•'
Aquifer Storage and Recovery Dli Salinity Barrier FROM TO • I MATERIAL • Tr ATLACEMENT METHOD _
Aquifer Test Q]StormwaterDrainage • ft ft. '
Experimental Technology D Subsidence Control ft ft
Geothermal(Closed ,.—Loop) 0 Tracer '2.:RILLINGSAG•(attac5 i1ditiin it s e'etsifaeceib •;'.:,1':'
0 aryl''"' • =
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,satl/rock type grain s ze etc.)
r J . 1 -- -
l, f �if�v�
4.Date Well(s)Completed. I(�f�� Well ID# Ab R 1�� rt.�����t mac, .
5a. _.
Well Location: `�'�_ fl fc t'. b n :ir1 "i .' •
•1 g •• ft
J p y
Facility/OwnerlName �` Facility ID#(if applicable) ft ft E
Phy'cal.ydress, and Zip ft •.; 71 .._ LR°,£
kheNbe) l36I 5M.t 6- .21:aRlEmARYSARys'._:?:.< :'�:`. ...::`'' ^ .- ;:1:' 1.r.>'w,.:.'::;•:'::•._, .
County ParcelldentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - _
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(if well field,one lataong is sufficient) 2 cation: •
Wit :.K 1 -N b i 51943 w •• •
C2 ii4e _P,3 _
6.Is(are)the wells) Permanent or DTemporary Sigma f tined Well Contractor • •Da
B suing is form,I hereby certify that the well(s)was(were)constructed in accordance
- 7.Is this a repair to an existing well: l +Yes or *No wuh ISA N C 02C.0100 or ISA NCAC D2C:0200(Yen Construction Standards and that a •
If this is a repah;fill out known well construction idformatton and erplain the nature of the copy of this 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: I`,t) (ft) 24a. For All Wells: Submit this form within 30 dayb of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2@,100') construction to the following.
10.Static water level below top of casing: (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 Injection Wells: In addition to sending the form to the address in 24a
y-/?l t f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 , J
construction to the following:
(i.e.auger,rotary,cable,directpus%etc.) • • •
FOR WATER SUPPLY WELLS ONLY: 1636
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&Injection 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 type()\�'ron,� , Amount (L r 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 • 1 I I• Revised 2 22 2016