GW1-2022-03761_Well Construction - GW1_20220404

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I.Well Contractor Information:
( ; l� /�IDV?7►Qti1 14:.WA.TERZONESc'.
WellContractorName U FROM TO •DESCRIPTION Y
ft. fL
'G T yfJ� 1
ft ft
NC Well Contractor Certification Number
15:'OU7ER:(?ASING,(foc multi-rased w@1s)OR I213ER(i-2'licable)'v;';°'; •.'.;
Morgan Well&Pump, Inc. FROM xo DEAMTER , Tffit�ss MATERAL
Company Name +1 ft (� ft.
t 61/8/ m;. Isdr11 pvc
16."INM CASING 012.7[IBII IG"eotfierma7 cIo'sed lod"
2,Well Construction Permit#:�ZI�',S FROM TO. DTAMR.TRR TfficMulass I MATERIAL
List all applicable well construction permits r e.UIC,Cowdy,State,Yatiance,eta)- ft ft
3.Well Use(check well use): ft ft in:
Water Supply Well: 17_-SCREEN',_J Agricultural FROM TO•.: DIAMETER•.:SLOT SIZE •.YT1iICKNESs �MATERiAL:-I•
$ �M cipal/Public ft ft in. _
1 Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft ft in.
1 Industrial/Commercial DResidential Water Supply(shared) _
I Ilmi ation FROM TO I EMPLACEMENTMETHOD&AMOIINT
Non-Water Supply Well: 0 ft 20 ft. bentonite• poured
[EXPUilnental
oring ORecovely ft ft
n Well:
r Recharge �
aGroundwaterRemediation
..'9:SAND/GRAVEL•PA;CK if a"lickb
r•Storage and Recovery OSalinity Bawer FROM -TO MATERIAL MY2LACEMENT METHOD`~
r Test QI Stormwater Drainage ftft Technology �I Subsidence Control ft ft
rmal(Closed Loop) Tracer
rmal(Iieating/Cooling Return) —I Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soillrock type grain size etc) '
4 ft q6 f a
4.Date Well(s)Completed:']22-22_ Well ID# ft 3 ft
5a.Well Location: 'Z ft ft T
8.7A1<t ft ft .,
ray
Facili /Owner Name Facility 1D#(if
�applicable)
�� ft. ft
ft
Physical
Address,City,and Zip/ ft ft
L�2(I�IO�I 'ZI:ItEMARKs'-' «;.- `:,'� _ -- .,. •moo;• - _
County PaxcelIdentificationNo:(PIN)
v�1+,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one latllong is sufficient) 22.C atiori
5t17b -N � � 316 g�-I( W
6.Is(are)thewell(s) Permanent or DTemporary Si, eofCertifiedWellContractor Date
By signing this form,I hereby cerYfy that the we11(s)Was(were)constructed in accordance
7.Is this a-repair to an eldsting well: Dyes or o with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Mell Construction Standards and that a
If this is a repair frll out known well construction information and explain the notw•e of the copy afthis record has beery 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-I is needed. Tndicate TOTAL NUMBERbf wells construction details. You may also attach additional pages if necessary.
drilled:_'
SUBMITTAL INSTRUCTIONS
9.Total well depth below zYn surface: 2Z
For muluple wel d (ft) 24a. For All Wells: Submit this form within 30 day5 of completion of well
k list all depths
if differ ent(example-3(a�00'mu12Q100� construction to the following.
I
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlerel is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b..For'Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 0 L above, also submit one copy of this form within 30 days of completion of well
(Le,auger, to the following.anger,rotary,cable,directpush,etc.) ,
F
R WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gprn) An Method of test all pressure 24c.For Water Suuuly&Iniectien'Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection type: Amount: +�`jdy completion of well construction to the county health department of the county
constructed.
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FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised2222016
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