GW1-2022-05821_Well Construction - GW1_20220609

1.Well Contractor Information: I I
__37C�(o TI 14:.DyATER ZONES
well contiAtor Name fiROM TO DESCRIFTION
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IL
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NC well Contractor Certification Number F
OU�'ER;CASII�rG,fnc multi=caseii webs)O#I I%IIQE).2(if a'licable',1:�::`,'.::.
Morgan Well &Pump, Inc. FROM TO. DIAirIETER T>�crvEss MATERL93
Company Name +1 ft-
5 ft- 1 61181I ' sd,21 pvc
16"ROM G OR.TUBING. eotli6iii l closed lod
7 FROM
2.Well Construction Permit#: TO DIAMETER THICET'ESS :LMATERIAL
1
List all applicable well construction permits'(ze. County,Stale,Variance,eta)-
ft. ft in.
3.Well Use(check well use): ft ft. in
Water Supply Well: 17 SCREEN'..;.'. =.:-
FROM TO DL.METER SLOT SIZE THLCKNFSs MATERIAL.
Agricultural DMunicipabTiiblic ft ft.
I Geothermal(Heating/Cooling Supply) Qli Residential Water Supply(single) ft ft in•
I Industria Commercial Residential Water Supply(shared) _,.: ,.:.:•.:•.;•�.:. ....:
GROUT.!...
[Geothermal
tion FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 ft 20 ft bentonite poured
toring Recovery ft ft
n Well: ft
er Recharge Groundwater RemediatioJarlu)
::19:S2.ND/GRAVEL•PACK if a"licableer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENT METHOD
er Test OStormwater Drainage ft ftmental Technology [3Subsideuce Control ft ftermal(Closed Loop) 13Tracerrmal(Heating/Cooling Return) Other(ex lain under#21 FROM TO DESCRIPTION(wlo,hardness,soiUrock a in s ze etc)
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4.Date Well(s)Completed: Well ID# f q o ft
52-Well Loca'�',on: Z) f, ft- f0 V f
Facility/Owner Name Facility ID#(if applicable) ft ft
Physical Address,City,and Zip ft ft
County U Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fie'ldl one]at/long is sufficient) , I 22-Certifi lion �"iDn Prcj Ca .04-.g URA
6.Is(are)the well(s) Permanent or Temporary Signa a of Certified eg Contractor Date 1
By sighing this form,I hereby cert:•ry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or I No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Fell Construction Standards and that a
Ifthis is a repair;fR out known well construction information a explain the nature of the copy ofthii 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 detaiis:
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:_ / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( � (ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells Art all depths if different(examp7e-3@200'and 2Qa 100) construction to the following.
10.Static water level below top of casing:_so (ft) Division of Water Resources,Information Processing-Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection WeIls: In addition to sending the form to the address in 24a
12.Well construction method: co �L� above,also submit one copy of thisfomi within 30 days of completion of well
construction to the following:
(Le-auger,rotary,sable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY VeTILS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) / Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
O-1 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: G1nr1 it U 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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