GW1-2022-05642_Well Construction - GW1_20220610

1.Well Contractor Information: I I
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ZONES-C. :. r..• .: •.•........_:.:,
Well Contractor Name TO DESCRIPTION
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NC Well Contractor Certification Number
15:O=R:G�ASING,(iorriinlfi=rasedwe3Ls OJ2LIIgE12 if' licahle' ".:
Morgan Well &Pump, Inc. FROM TO' DIAMETER THIt KNM I MATERIAL
Company Name +1 ft- � 61/8/� in' sdf21 pvc
p y /� QQ I6.-DWER CASING OR•TOBVG:' eotfierinal'clo'sed-lod`
2.Well Construction Permit#: EHkl C_<. V�D lS FROM TO DIAMETER TEICKNESS MATERIAL'
List all applicable well construction permits'(r.e.UIC,County,State,Variance,etc)• ft. ft. in.
3.Well Use(check well use): ft• fL in.
Water Supply Well: 17_-SCREEN',=:. .:. <.- =•`:.:._ :,:. ::-',.:'-:.:.;..;r.- :;.:.
FROM TO DUMETE7 SLOT SIZE THiCKNMS MATERIAL.
Agricultural nMuaicipal/Public ft. ft
Geothermal(Heating/Cooling Supply) �ideatial Water Supply(single) ft ft in•
Indus�Commercial J Residential Water Supply(shared) -'IS'-GROUT:;. '` "- '[Experimental
tion FROM TO MATERLAL - EMPLACEMENTMETHOD&AMOUNT
ater Supply Well: 0 ft 20 ft bentonite poured
oring Recovery ft ftn Well;er Recharge OI GroundwaterRemediation�, •.19:Si1ND/GRAYEL'PACK if k"licablier Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHODer Test Stormwater Drainage ft• ft
mental Technology Subsidence Control ft ftrmal(ClosedLoop) Tracer20.DRILLING.L'OG'(attacliaddition'slsl?eetsnecess j;:: => -_rmal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type s ze etc)
4.Date WeU(s)Completed:s' y—2? Well ID# f, 190 f,-
SSR.Well Location: � f- ft raht�-EG
Ckri5 Leo- ft ft-
Facility/Own&Name nn '' Facility ID#(if applicable) ft ft
J2 6 sake Ity- l'��(� ft ft
Physical Address,City,and Zip T ft ft
LIKCd�✓L '21:u'Fnreuuc'- - -:,•- _ _�'.�;�'g�;',.�'.."' _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) a 22.Cerrttificatio :
N - �. / 0 35 7�_W pl bnfo,sria icri Pfo ti rg Ung
a A� U'ik1oyaoCe -ZZ
6.Is(are)the well(s)omanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certzfy that the weil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or Ckql- with 15A NCRC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well consti•uction information and explain the nature 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 NUNMER'of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �7)5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esample-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 30 (ft) Division of Water Resources,,Information Processing Unit,
Ifwoter level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: 6 (in.) f 24b.For Iniection Wells: In addition'to sending the form to the address in 24a
12.Well construction method: r o�r LI above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direetpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) !J Method of test: air pressure 24c.For Water SuDuly&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:illoYim, Amount: got completion of well construction to the county health department of the county
where consttutted-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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