GW1-2022-03181_Well Construction - GW1_20220307

actor Informatim-
14:.WATER ZONES a'.
Well ContractorN Aa FROM TO DESCRIPTION r
ft ft
J ft ft
NC Well Contractor Certification Numbef
15:oIrm. CASING,for multi-eased wells)b7ELMorgan Well&Pump, Inc. FROM tTCENS Sif a linMA
+t t/S/ sd21CornPanyName pvc
`
33,s9 1n:IlVI�RCASIl�TGORTIIBII�G. -eotlie'r`malcio'se3ltid .' "='-_' :-;%
2.Well Construction Permit#: 7 FROM TO DIAMETER THICENEss MATERIAL`
List all applicable well construction permits'(:e.WC,CaatK Stale,Paitance,etc.), ft R in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 12:SCREEN'.:,:. .
FROM TO •:-`. DIAMETER.•• SLOT SIZE •THICKNESS IMATERIAL
Agricultural
Agricultural 0Municipal/Public n f, in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft
1 Industrial/Commercial Op Residential Water Supply(shared) GROUT.* -
lni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite. poured
'Monitoring DRecovery ft ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft ft.
•.19:SAND/GRAVELTACK d a•hcabl
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft
+Experimental'Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILIaNG.LOG'(atta6'sdditi6il sUedjf i eces's"_ _
Geothermal eatino COOlin Return FROM TO DESCRIPTIO (cafe,hardness,soil/rock tyr e,grain size,etr-)
(H � $ ) �Other(explain under#21 Remarks)
4.Date Well(s)Completed ZS ell ID# ft ft
a.1Well oca��/Jp _ 0 ft ft.
1 l v ft ft kU
Facility/Ow erNName� Facility ID# a�p�flic�abl�e)�nJ ft ft.
•� ' I V�- O"!D ft ft �'f aymT"3 a: I
ical Address,City,and Zip A r I (^) ft. ft " T
County Parcel Identification No.(PIN)
sissy
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �"' '`— �--�
el I L na is sufficient a:..e 'it4a ti Iv. i
)N W. ✓�IG�� 22. cation: i;'
6.Is(are)the wll(s)*Permanent or ©ITemporary Si' a ertified Well Contractor Date
sig is form,I hereby certifythat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No Uh ISA NC4C 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a trepan;ftll out known well construction information and explain the nature ofthe copy ofthii record has been provided to the well owmer.
repair under#11 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: tl SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3 a 00'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
.I'water level is above casino 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
12.Well construction method: O Y LI above, also submit one copy of this jform within 30 days of completion of well
(i e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �D 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: � Amount: DZ 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 J Revised 2 22 2016