GW1--04843_Well Construction - GW1_20230728

YY11LL LU1Na1.N.UU11UN RECORD'(GW-1) For Internal Use Only.. • •
1.W ontractor Inf -mation: I
• ,' :, -
•14:.WAThat.ZONES - : ..•• ,...i..•- .: •.,..,. ....-<.:; :.•.. _ .
Well Contr for ame. •
FROM TO DESCRIPTION
!f/�►` ,. r ft ft
e
r ft ft.
NC Well Contractor Certification Number
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15:O U..'.PaR CASIN( ,(ibr multi-cased Svells)OR LINER(if ap licable)%e:::-.`:.;:'•.-.:
Morgan Well &Pump, Inc. : FROM O' DIAIlIETER ; THICKNESS MATERIAL
Company Name +1 ft ft 61/8/ in' sd21 pvc
C ^r6,. 16`M.E.R CASING OP:.EU1iTaGG(beothermai•cio'se3lodp)4c:,:-`'•a' I.
;_':.
2.Well Construction Permit# G'(2 r O�,s FROM TO DIAMETER TEICIiNESS MATERIAL'
List all applicable well construction perntits'(i e.WC,County,State,Variance,eta)• ft. ft . in,
3.Well Use(check well use): ft. ft. in
Water Supply Well: . 17_-SCRFEN, ..,.'t:, ._..- . - t,.- ;
FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL.-
Agricultural QMunicipaUPublic • ft. ft. in.
_._ _.. !Geothermal(Heating/Cooling Supply) gIResidential Water Supply(single) ft • - ft in.
hidustriaUCommercial Residential Water Supply(shared) ;.18:GROUT•:..... : t•,, ,:.: ='._. •
• 1 Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOIINT
Non-Water Supply Well: o ft 20 ft bentonite• poured
Monitoring Recovery ft. ft
_Injection.Well: -
ft ft.
_Aquifer Recharge DI Groundwater Remediation
Aquifer Storage and RecoverySalinity Gamer :•1•SAND/GRAVEL'PACK(if applicabre)' _{;:;:'.::-'•:.'•,-:"•;:•_'•':• ':.`
FROM TO • MATERIAL • EMPLACEMENT METHOD
i Aquifer Test QlStormwater Drainage • ft ft. .
I Experimental Technology DI Subsidence Control ft ft.
Geothermal(Closed Loop) 0Tracer . , :20.DRIISIlQG1;OG'(attaciisdditiori'slsheets.iffiecessaiyj: l.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(colo,hardness,soil/rock type grain s ze ere)
r P''�(sfr >
4.Date WeIl(s)Completed ` Well ID# ft• 35Sa.Well Location: ' S 45 'C
• Wai, \k8.4bte% yS ft. IS ft.loYbWvt rc L
Facility/Owner Name Facility ID#(if applicable) II5 D VD11+ft.tkU�,tyyy,'_L
e Moue�b b wC _ LZBL ft -+ft l" p^-a i-T V F O
Physical Address,City,and Zip ft. ft. t -6''�1... i Y,•e m,.,.0
•
21.iatIMeRuc .. :81p
County .Parcel Identification No.(PIN) •
i(1tCii, l.c.n 7rrc..zro GPg Ur.;--.
5b.Latitude and longitude hi degrees/minutes/seconds or decimal degrees: ey
(if well field,one 1at/long is sufficient) Q [�Ci {} +fit!J
-3S.L46c6 'N cab a -\ `'� W 4. aton:j >
6.Is(are)the wells) Permanent or QlTemporary Signa.a rtifed Well Contractor •Da e
Bning,is form,I hereby certf),that the well(s) was(were)constructed in accordance
7.Is thiq a repair to an existing well: 0Yes or ®No with 15AN•t.0 02C.0100 or ISA NCAC 02C,0200 Well Conshvction Standards and that a •
If this is a repan•,fill out(mown well construction information and explain the nature of the copy ofihis 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: 4o :" (f) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: o (ft) Division of Water Resources,Information Processing Unit, •
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
•
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�—(}i' ( ,� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: U t " J construction to the following:
(ie.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) 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 �1(�N,�j Amount: (( DZ completion of well construction to the county health department of the county
where constructed-
FermGW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016