GW1-2022-05613_Well Construction - GW1_20220610

1. Contracto ormation:
��� 14:.WATERZONES -
Well CoffsdtorName FROM TO DESCRIPTION
M ft
ft &
NC Well Contractor Certification Number I
15:OU�ER,CASIN�,(far multi=used weIls)O$III1FlZ(if a
Morgan Well &Pump, Inc. FROM TO' I DIAMETER' I T310ENMS MATERLS3
Company Name +1 ft 2 ft- 61/8/ I I" sd,21 pvc
16`INNER CASING OR-TUBING. eotfiermal closed 306' :
2.Well Construction Permit#: � -111 FROM I TO DIAMETER THICKNESS :+pMATEI27AL
List all applicable well construction permits'((.e.UIC,Cowtty,State,Variance,etc)- +ftft. 1n.
3.Well Use(check well use): f, in.
W:A96cultural
r Supply Well: 17_-SCREEN.>>'.. '::. .'�,. .. :;•: •..:�: ::_ti,.r'�,::=G: ,. -c::.:. .: ::
FROM TO DIAMETE SLAT SIZE TAICICNESS MATERIAL.
DMuaicipal/Public ft ft in.
I thermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft
I hadustn ommercial I Residential Water Supply(shared) -GROUT::. _ '` '•_::' - -
Ir i tion FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
:Monitoring Recovery ft ft
Injection.Well: ft. ft
_I Aquifer Recharge Groundwater Remediation r
•.19:SANDlGRAVEL'PACK if a'�Iicibl8 - .. :.
Aquifer Storage and Recoveryt Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
�AquiferTest QlStormwaterDrainage ft. ft
f Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRMI ING.LOG-(atticfi`addit!aAI slieetsSf aecess +,..7'
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIP ON(olor,hardness,soiVrock type in size,etc.)
c 't O It
AC5 ft
4.Date WeJl(s)Completed:"1( Well ID# 5. ft A f-
Sa.Well cati r
fL
1, \.j ft ft
acility/Owner Name Facility lD#(if applicable) ft ft 0 202
YIN . ft ft
. _-
--,�.°s'i g Uri!
P sical-A`ddrdressss,,City,and Zip (�Jy�[� ft ft VQ E /-OG
v
Ub Z1cRFMARKC° - -:J" '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q� 2 G Ct a
cation:
3S.(Q(Qq�1 "N Uy . J J�T W Z 2-7i-
6.Is(are)the well(s)'SPermanent or OITemporary S' r ertified Well Contractor Da
y sin tine is form,I hereby certify that:the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or JkNo with 15.4 AU4C 02C.0100 or 15A NCAC 02C.0200 T7ell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 GeoprobeMPT 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 n SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (►�� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we&list all depths if&fferent(example,-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 4-0 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;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
12.Well construction method: Q L� above,also submit one copy of this'form within 30 days of completion of well
construction to the following:
(i e.auger,rotary,cable,directpusi- etc.) iI -
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2,0 Method of test: air pressure 24c.For Water SuDDIv&Iniectdori 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 typ : Y Amount:_ 8Z 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 .I Revised 2 22 2016
f
i