GW1-2022-05620_Well Construction - GW1_20220610

L.Well Tctor Info- on: I I
•14:.WATERZONES:'. ':•: � .�',..�..• .: :...... ...._+.:; :. .. .:• ':
Well Co actor e A FROM TO DESCRIPTION
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NC Well Contractor Certification Numbet 1 I
15:OUi1 R:CASING,foi•mnlii=raked
Morgan Well&Pump, Inc. FROM TO' I DIAMETER THICIfIMS MATEx14L
+1 ft. ft. s 1/8/ lin. sdr21 pvc
Company Name ..
16.•12•II�I2 CASING ORTDBII�G. 'eotliermalclo'sed--lod
2.Well COnStI action Perinit#: P��?j� FROM To DIAMETER THICKNESS MATERIAL' ~
List all linable well construucdon ermits Le. M ft in.
apP• p (' C,Cowrty,Stale,Variance,etc)•
3.Well Use(check well use): ft ft to
Water Supply Well: i�SCRFEIQ'.,:. ; :::. .`,: <: .•;..;.•i -;.,r=..:'.;::• r•"r: :'
FROM TO DIAME SLOT SIZE THICKNESS MATERIAL .
Agricultural ]Municipal/Public ft ft in
Geothermal(Heating/Cooling Supply) pResideatial Water Supply(single) ft ft in.
I Edustn Commercial J Residential Water Supply(shared) 18:GROUT[Aquif6r
tion FROM TO MATERIAL EMPI.ACEMENTMETEOD&AMOUNT
ater Supply Well: 0 ft 20 ft bentonite poured
toring Recovery ft ftn Well: M fter RechargeI Cn oundwater Remediatioa 79.SAND/GRAVEL-R,.QK if a"licibl--eer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHODer Test DStormwaterDainage ft ftimental Technology Oj'Subsidence Control ft ftermal(Closed Loop) �ITracer :28.-DRILLING.LOG'(ittiili:ddition"slsieefsifieEegFROM TO DESC IPTION(color hardneu,soilhock tY e,grainrmal(Heating/Cooling Return) J Other(explain under#21 Remarks) 1�
q y .ft d ft
ID W
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4.Date Well(s)Completed: !�� Well # it I q5 ft
,r
Well' 5 ft ft
Location- ��
O ft.15 0ft a/`0.,jui :r
Facility/Owner Name Facility ID#(if applicable) ft ft.
rD
=�- ft fL P 1
ical Address,City,and Zip ` ft ft. N
C&mty Parcel Identification No.(PIN) r117
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation:3s"''I2�2 -N $a.53�13 W s /, u
6.Is(are)the wll(s)*Permanent or OTempor2ry Sign ertified Contractor D to
I-
. is form,I hereby certify that the well(s)was(were)constructed in accordance
well:- 0
7.Is this a repair to an elasting well:- Yes or JrNo with]SA NCAC 02C.0100 or 15A NC,4C 02C.0200 Well Construction Standards and that a
if this is a repair•,fill out known weA 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 thisform. 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: 5 4vh (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2P0 and 2@100) construction to the following.
10.Static water level below top of casing: Ut-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino 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
12.Well construction method: L1 above, also submit one copy of this jform within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPP LIS_ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
P
13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniectiori 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 d \PJJ Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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