GW1--07139_Well Construction - GW1_20231101

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• WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: .
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FROM DESCRIPTION
Well Contractor Name • e O
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4550-A WO ft ft. }
NC Well Contractor Cert ficationNumber -15;OTORItZ(9S71V,Gi(fpr;;mu-h c93e'd sgells)'yOR�Ih,Il`IEIZt(iftupp)cable)` EM-. '*: •
Morgan Well &Pump, INC FROM TO DIAMETER 1 THICENESS MATERIAL
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Company Name j f/^ �: �'�„ ,�: �-�r'•
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V 11 {KJ 1 MATERIAL
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MA t Wirer.
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft ft. in.
3.WellUse(checkwelluse): yT cr �fft. yft 1 ill.
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Water Supply Well: FROM TO DIAMETER SLOT Cm' THICKNESS MAmERrAL
X Agricultural 3Municipal/Public ft. ft. in. ,
11 Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft in,
*Industrial/Commercial DResidenlial Water Supply(shared) .4$lGWITD. ? :r it• �"` `• .:" �_ -_ `=~r fia- ..07 :r:
-:.�u.-_._,-:::a: =�•_,.°.m-'�;m� �_ ����.::.����. ,�w•.•.'jig
Qrrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 6 -ft. elp ft. feivilto t,�-___ VV u(t )
Monitoring MIRecovery ft. ft.
Injection Well: ft ft.
11•.uifer Recharge DGroundwaterRemediation ', /• Gg licatile?w- '=' v },'_, n. ;s,-
S41ND(T2A"YI,"AA °tiM 7. .ei-?it:i�-.r,;"^ --. -i MAT.
*Aquifer Storage and Recovery ©ISalinityBarrigr FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test ©IStormwaterDrainage ft ft
•Experimental Technology I�1Subsidence Control ft ft
Xi Geothermal(Closed Loop) ®ITracer Aoailtruat,*.ZOG(attjtat'addifon`s1;s'hegts eceesary=Wei # v 4=i+ tri
Geothermal(Heating/C,00ling Return) Other(explain under#21 Remarks) FROM TO D CRIPTIo (color,hardaess,soivroek type grain size etc)
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4.Date Wells)Completed: t6r�S'1$ Well ID# if??ft ft. co Irv1`J 11.a Ckw •
5a-Well Location: •
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Facility/Ow11nerName / �1 11FacilityID#(ifapppliccable) ft ft -.:- , T-_ -
Q11.5 \tgl .� 1 li `IS b( Vrl�i ft. ft. - ;T E..,^ .y:
• Physical Address,City,and Zip
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County Q Parcel Identification No.(PIN) IP'0, •.7.•1 ° _ ..
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well eld,onn n 4 5 11 sufficient) Q� 22.Certification: •\
5. , ( Ya(/ N F6 . w 6 � Wli
• 6.Is(are)the wells) ermanent or ©ITemporary
• Signature of Certified Well Contractor • Data
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jXNo • with I5A NCAC 02C.0100 or 15ANCAC 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 remarks section or on the back of this form.
23.Site diagram or additiopal well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction deinils. You may also attach additional pages if necessary.
•
' drilled: 1-r• SDBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �l� (fk) 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2 00D construction to the following:
10.Static water level below top of casing: (f.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 ,
11.BorehoIe diameter: (in) 24b.For Infection Wells: In addition to Sending the form to the address in 24a
12.Well construction method: 1 LO'
1 R_ T r • above, also submit one copy of this form within 30 days of completion of well
� construction to the following: i •
(ie.auger,rotary,cable;direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 ' Method of test:.'4(C •{ ( ' 'Imo- 24c.For Water Supply&Injection Well 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:�"r i, 4 aC- Amount l l V 1,s completion-of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Aepartment of Environmental Quality-Division of Water Resources i Revised 2-22-2016