GW1-2022-05617_Well Construction - GW1_20220610

L W 1 C'nntractor Inform I �1
14:.WATER ZONES-,', .: :I:- '.... :}',....'..':'..._:.:, ;.
'Well Co rName FROM TO DESCRIPTION
ft ft
ft ft
NC Well Contractor Certification Number
15:OU7ER:CASTNG,(focmniti=cased;we➢s b�2III�rER rf licahie)'
Morgan Well&Pump, Inc. FROM TO' DLQIETER THICKNESS MATERIAL
Company Name +1 ft 3 ftii 118/I in. I dr2l pvc
16MIIM CASING OR•TOBING. 'eothermal
2.Well Construction Permit#: FROM TO DIAMETER THICE2gESS MATERIAL'
List all applicable well construction permits'(r.e, 07C,Cowgv,Stale,Va7*=e,etc). ft ft in.
3.Well Use(check wail use): ft• ft in.
Water Supply Well: I. IVSCREEN',:-'.::a_:. .`�; •.a°_.: ;:,:. i•; .::=;:.,r.- ';.. .::•;
FROM TO DIAMETER SLOT SIZE .THICKNESS TYIATEML . ,
1 Agricultural CiMuaicipal/Public ft ft in.
z Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft
I Industn ommercial J Residential Water Supply(shared) GROUT:: =`[Aquifer
tion FROM TO MATERIAL I M I ACEMENTMETHOD&AMOUNT
ater Supply Well: 0 ft 20 ft• bentonite poured
oring Recovery ft. ft.
n.Well:
ft fter RechargeI Groundwater Remediation er Storage and Recovery Salim Barrier ''�:SAND/GRAVEL-PA:W if a:'licabre "tY FROM TO MATERIAL EMPLACEl4fENT METHODr Test DStormwater Drainage ft ftmental Technology Subsidence Control ft ftrmal(Closed Loop) OTracerrmal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock tppq grain s ze err
o � h
4.Date Well(s)Completed '� Well ID# b ft [so ft
5aWeil Location: /t �� ft Z ft
ft ft
Faacility/OwnerName Q Facility ID#(if applicable)
p �r ft ft
6 1 5a � ft ft K ?
cal Address,City,and Zip ft ft s
County PatcelIdentificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiel one lat/long is sufficient) 22.Certification:
-N -b• AzoN W
6.Is(are)the well(s)APermanent or [)Temporary *754
ed Well Contractor Dat
orm,I hereby certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JjNo 02C.0100 or 15A NC4C 02C,0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature ofthe copy ofthii 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 bf wells construction details. You may also attach additional pages if necessary.
drilled: SUBh=TAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple'wells list all depths ifdifferew(example-3(a)200'and 2@ 100) construction to the following.
10.Static water level below top of casing: 315 (ft.) Division of Water Resources,Information Processing Unit,
)Twofer level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
L�
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: constructionconstruction to the following:
(Le.auger,rota cable,directpusb,etc.)ry,
LFOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) Method of test: air pressure 24c.For Water SuDuIv&Iniection'Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection Amount: OL completion of well construction to the county health department of the county
where constructed_
a
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016