GW1-2022-03795_Well Construction - GW1_20220404

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1.Wn�lWontractor Inf,rm on:
14:.V/ATERZONES•:'.
Well n ctorNanie FROM I TO - I DESCRIPTION
ft ft
3V��
• ft ft
NC Well Contractor Certification Number
15:OUTER:eASING,(foi multi-rased*6M)'O,R IMWR(if a'licehle)' :::'.:'.::'•.
Morgan Well&Pump, Inc. FROM TO DIAMETER THICIMESS MATMAL
Company Name +1 ft, r� ft. 6Ila/ � �iu- sdr21 pvc
� j�+r,�f��/,I/�/J •��f (/J� 16.`7NNEFt C' G OR•TIISING'"eotherma7-closed-loo` }`:.``'•�' '•:%�'•'•�': "
,2.Well Construction Permit#:L�J// zz �D• /- FROM TO I DIAhSTER I THICKNESS J MATERIAL
List all applicable well construction permits'fl.e.UIC,Cowgg State,Variance,etc.)- fr• ft, in.
3.Well Use(check well use):' ft ft in.
UJAgricultural
Supply Well: I7:SCREEN', -
i—�� FROM TO - DIAMETER i SLOT srZE -TArc&-"zs MATERIAL
ElMunicipal/Public g• ft- yr„hermal(Heating/Cooling Supply) f pResidential Water Supply(single) in.
stria/Commercial []Residential Water Supply(shared) 18-.GRO1jT•::. _ .`_.:.•_:-
'hri ation FROM TO MATERIAL I EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft. �20 ft, bentonite• poured
'•Monitoring DRecovery ft. ft
Injection Well:
ft ft.
Aquifer Recharge DJ!Groundwater Remediation
Aquifer Storage and Recovery Salmi Barrier ':19:SAND/GRAVFS:•PACK if if blicable :'.;:_':: :;'= :• :'::
ty FROM TO MATERIAL I EMPLACEMENT METHOD
i Aquifer Test 139tormwater Drainage ft ft
J Experimental Technology U Subsidence Control ft ft
Geothermal(Closed Loop) 13TYacer :20.DRILLIIVGS OG'attacli`addition'al sliee6 if nec0 " 5
I Geothermal eating Coolie Return) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
g ) _ Other(explain under#21 Remarks) ft ! ft. ye' dam!_
4.Date Well(s)Completed:..?/7-Izz., Well ID# /s ft. ft-
5a.Well Location: ft ft J v
sa �r,$ ft v ft
TF-I!Ouerj�Naa"me II J_ n Facility ID#(if applicable) ft. ft
�12q&e_CU-6VC C1r yl�{r' ��. Z�037 ft ft
P yss-Ical Address+,City,and Zip ft ft
_L1• 61 :•21c'RYi.MdRKC' - �:i i `� _- - -_ -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p
(ifwell field,o lat/lono is sufficient) ga
cation: APR —•4 2022
W
6.Is(are)the well(s)APermaneut or OTemporry Certified Well Contractor t�
�j�, 16a�r, lir F t•r
By sig nng this form,I hereby certify that theE w`(-V was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or JWNo wa7,15A NCAC 02C.0100 or 15.4 NCAC l)2C,0200 Mell Construction Standw-ds and that a
Ifthis is a repair fill out(mown well construction information and explain the no ut•e ofthe copy ofthis 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 bf wells - construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 46y (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells List all depths##different(example-3@200'and 2(Q100D construction to the following.
10.Static water level below top of casing: L(O (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Il.BorehoIe diameter: 6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method �� �L� above,also submit one copy of thus form within 30 days of completion of well
(Le.auger;rotary,cable,directpush,etc.)
gconstruction to the followin \
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYQWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (� Method of test air pressure 24c.For Water SunpIy&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 type: 06 Kit, Amount: completion of well construction to the'county health department of the county
where constructed:
Form GW-1 North Carolina Department of Enviromnental Quality-Division of WaterResources Revised 2 22 2016
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