GW1-2022-03174_Well Construction - GW1_20220307

actor Information:
t
14:..WATER ZONES-,',Well Contractor a FROM TO DESCRIPTION .
ft ft
ft ft
NC Well Contractor Certification Number i
� '15:OU7.'ER:CASIl�TG',(foc multi=caked webs OR L-II�ELL if." lirahle): :�::'j.:;'•.`.1
Morgan Well&Pump, Inc. FROM T DIAMETER THICKNESS MATERIAL
+1 ft. O ft. 61/8/1 in. sd21 pvc
Company Name
i��o O J 16.lNNER C' G OR T17B11�G.' eotfiei�sl dosed loo` : =
2.WeIl ConstructionPerrnit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction periRTs rLe.M,Cowity,State,Variance,etc.)- M ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17--SCREEN'•:- �:' .::;,.: <: ?. 'K:;.:. .:: •' .::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMuoicipal/Public It
ft in.
Geothermal(Heating/Cooling Supply) IpResidential Water Supply(single) ft ft in.
Industrial Commercial Residential Water Supply(shared) :_:,• .,_.:.,;._ ., _
I i.i ati. FROM TO MATERLLL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft* 20 ft bentonite poured
'Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge [3Cnoundwater Remediation
;:19:SAND/GRAVEL-PA:. if a"licabre
Aquifer Storage and Recovery Oi Salinity Barrier FROM TO MATERIAL EMPLACEMENT`METHOD
IJ'Geothermal
Aquifer Test DStormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(ClosedLoop) �_J_'•ITracer :20.DRUEING.LOG'(attiiEaddition'ilibiiedjfaeces-s_-j:
(Heating/Cooling Return) r-li Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,eta)
1 2 d ft t 5' ft
4.Date Well(s)Completed: ZI tWell ID# 1 45 fl 35 ' lr(—
e11L cation: ft !Oslt Llcb.(Of GV
ft � ft
IN
Fa iltty/Owner Nam han, :p 1Facility lD#(if a plicable) n ft �f wit `
�/iyC ft v.....�ft
al Address,City,and Zip CJJ ft ft
21:3tEMARKSF.
County Parcel Identification No.(PIN)
n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `^ ^rrn ,r
(if well field,one lat/long is sufficient) 2 er cation' t•^• '�`4 Y`:w
3 �CQ( N OO 517 3 ( ,�p , _
W r'�11J�`trr '1t FLl'tY Fi4 5•iii alfa11
6.Is(are)the well(s)ffiPermanent or 13Temporary Siw e o ertifie ell Contractor D e
B si ni th form,1 hereby cerliify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or J§No itl II NCA 01C.0100 or I5A MCA 01C,0200 Well.Construction Standards and that a
If this is a,epait,fill out known well construction information and explain Are nature of the Y ofth' ord has been provided to the well owner.
repair under 421 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 l GW-I 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 land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-(3Q200'and 2@100) consh uction 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
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: `r 01'A Y LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuuDly&Iniection 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 typo Amount: 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 Revised 222 2016
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