GW1-2022-05607_Well Construction - GW1_20220610

1.WeI3.Eontracto ormation:
a Lug14:.WATESt ZONES
Well on Name FROM TO DESCRIPTION
�q?z ft. ft.
ft ft.
NC Well Contractor Certification Number
'15:OIIT'ER:CdSING,focmniti-risedweIls O_•L•II�xt(if._.IIcable'1:�::'.:,::.•..
Morgan Well &Pump, Inc. - FROM TO. DIAMETER THICKNESS MATERLsL
Company Name +1 ft S& ft I 61/81 1 in- sd21 pvc
�A 1RCASINGOR.TIIBING. -eotliermal•clo'sed-loo� .'
'.'•~
2.Well Construction Permit#: FROM TO DIAMETER THICKNEss I MATERIAL
List all applicable well construction permits'rL e.UIC,Cawgv,state,Ym lance,etc.)• ft ft in
3.Well Use(check well use): ft ft in.
Water Supply well: FROM TO DIAMETER SLOT SIZE" YTHTCKNESS MMATERIAL .
Agricultural DMunicipal/Public ft ft
g_Geothermal
(Heating/Cooling Supply) IrResidential Water Supply(single) ft ft in.
)in dus1na1YCommercial i Residential Water Supply(shared)
1Irri ation FROM TO I MATERIAL EMPLACEMENTMETHOD'&_4MOIINT
Non-Water Supply Well: 0 ft_ 20 ft• bent onfte poured
Monitoring Recovery ft. ft
Injection.Well:
_- Aquifer Recharge I Groundwater Remediation
•.19:SAND/GRAVEL•PACK Cif a:"linable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT xl2ETHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OITracer :20..MRMUNG.LOG'(attac6'sddition'EI
i Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM To DESCRIP oN(color,hardness,soiUroek ty e n size,etc.)
4.Date Well(s)Completed" 1 [J� weu 1D# 5 nL45ft 66.,16 y
5 .Well Location- o ft ft.
1 ft M s"�•
Facility/Owner Name Facility ID#(if applicable)
DU eYesg P t�G<-,-6 WH 7fL 0 20 2
Plwical
lA`dddrres`s.CC`ity,and Zip ft ft ln�ilPr`ii3s'd£ 1
\!Y• �O •9 unit
County Parcel Identification`No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lloong is sufficient) Q Q �] 22•C lion:
3S.rnq L N 0--s �-( W �.
6.Is(are)the well(s) IPermanent orITemporary Signa C ed Well Contractor Da
By o o t orm,1 herebv cer•tffy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Ji No w' 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction S'tandm-ds and that a
If this 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 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 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: ' 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: <►W (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffet eni(example-3 20D'and 2@100) construction to the following.
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater Jerel is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f-Q", L` construction to the following:
(Le.auger,rotary,cable,directpush,etc.) 0
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 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: completion of well construction to!the county health department of the county
where constructed_
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources - Revised 2 22-2016
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