GW1-2022-03768_Well Construction - GW1_20220404

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1.Well Contractor Information:
.14:.WATER ZONES•:'. -
Well Contractor Name FROM TO DESCRIPTION
��S o A b° ft
ft ft
NC Well Contractor Certification Number
15:Ou=,QTAS' Gfo &a -dise *ins)Q9 LM4ERN K a licatle -
Morgan Well&Pump, Inc. FROM DIAMETER THI MATERIAL
Company Name ^ \ +1 ft `� ft 6 1/81 sdr21 pvc
�1 V 16 INN'ER CASING OR•TfJBII�G.' eotliei�s7 closed loo
2.Well Construction Permit#: 1 FROM TO DL4METER THICKNESS MAT>RIAL
List all applicable well construction permits'rL e.UIC,Co-iv State,Variance,etc.)- ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: M'SCREEN'.;-.. `::. . •_'::::.:.:'r:. t. ::K:;.:. .:::° .
FROM TO DIAMETER SLOT SrZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
1 Industrial/Commercial Residential Water Supply(shared) 18rGROUT::•-
hair ation - FROM TO MATERIAL - EMPLACEMENT METHOD&.AMOUNT
on-Water Supply Well: 0 ft. 20 ft bentanite poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
_J Aquifer Recharge �i Groundwater Remediation
Recovery and Storage
Aquifer •.19:SAND/GRAVEL-Et CK if a'licablb
Q g ry ©ISalinity Barrier FROM TO - MATERILAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft ft
Experimental Technology OSubsidence Control ft ft
t Geothermal(Closed Loop) OTracer :20.DRILLING.I;OG-(attacli=addititirisl sLeets.if uecess"-j •= _
I Geothermal(HeatineCooling ReWm) ril Other(explain under#21 marks) FROM TO D CRIPTION(color,hardness,soilfrock type in size,eta)
9:91ft O ft lrA-
4.Date Well(s)Completed: Well ID# ft ft.
Z. n
5a ell Location: Oft.
y ICJ -Vt. �f°
Facility/Owner Name I` Facilitty ID#(if a plicable) ft. ft
L`O�� — MWe.(tfle�L^ !L� ft ft
Physical Address,City,and Zip ft. ft
-
County Parcel Identification No.(PIN) k
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell e l one lat/lona is su cient) 22.Certification: APR
-N 8PO- �� 7/ W
6.Is(are)the well(s)�,Permanent or Temporary Sian a ofCertified Well Contractor vdr ti a^ii� Y s9 I
By signing this form,I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E5U. with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iftliis is a repair,fill out known 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 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 ifnecessary.
drilled: . - U SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: % U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells llst all depths ifdierent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: y (ft) Division of Water Resource's,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method �0 Y L� above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta)
construction to the following:
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 Sunnly&Iniection Wells: In addition to sending the form to
I the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:9 fGn��q( Amount: IC7 b 2� 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 2-22-2016
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