GW1-2022-05824_Well Construction - GW1_20220609

1. weu t-onrracror intormanon:
14:.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft.
ft ft i
NC V'ell Contractor Certification Number '
15:O=RC QAMNG,(fo"rmulti-casaawe11s)OftIdMR(if ]icahle'
Morgan Well &Pump, Inc. FROM TO' DIAMETER THICKNESS MATa.Rrnx.
Company Name
+1 ft ft 61/8/ to sd,21 pvc
1 1 16.-neM C' OR•TD ' •BING. eotfierma7 do's8d loo' i. = }:%
2.Well Construction Permit#:__ FROM TO DIAMETER THICKNESS I MATERIAL'
List all applicable well construction permits(Le.L7C,Co Sky,State,Variance,ete-)- R ft. I in.
I Well Use(check well use): ft- ft in.
Water Supply Well: 17_"SCREEN'„
FROM TO DIAMETER SLOT SIZE THLCrOMS I MATERIAL.
ASncul ral CDMuaicipalRublic ft ft
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
I Tndustrt ommercialLjResidential Water Supply(shared) GROUT-.'... -
fN
tion FROM TO MATERIAL HAVL_4CEMENT METHOD&AMOUNT
ater Supply Well: o ft 20 ft bentonite poured
oring Recovery ft ft
n-Well:
ft ft
er Recharge Cnoundwater Remediation rGRAVEL•PACK if a:'iicabl'e :_.:er Storage and RecoveryISalinity Barrier FROM TO MATERIAL ErMPLACEMENT METHOD`rer Test DStormwater Drainage ft ftmental Technology Subsidence Control ft fL
ermal(Closed Loop) Tracer :ZO.DRII.LIIIG LOG'(atticli iddiaonal slfeetsifiecess-ky:�rmal g ) ( ) FROM TO DESCRIPTION eclor ardness,soiVmck type, in size,ete)
(Heating Coolie Return) -i Other(explain under#21 Remarks �ffi !
7
4.Date Well(s)Completed: ell ID# 13 ft ft Q::_/
52.Well Location: fL Q 't V V '
Facility/Owner Name Facility ID#(if applicable) ft ft
Pbysiic�al/A'ddeJressss',City,
,aan'Zip ft ft :�®
J 4/J V V' 4 `)O i '' •21:12`FMARKR - �:r" _ - - ,{@= _w.�::'• _
County Parcel Identification No.(PIN) JUN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) . JJ 2 22.Certification: Inlof�fi"J Pr �Ang Uni
'N 91• l!01 1 J� W
6.Is(are)the well(s) Permanent or OTemporary SignjorofceAed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with 15ANCAC 02C.0100 or 15A NCAC'02C,0200 Well Construction Standmds and that a
Ifthis is a repair,fill out known well construction information a d explain the natw•e ofthe copy ofihis record has been provided to the well owvrer.
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 NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IZZ (L) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'(aa d 2@100D construction to the following.
10.Static water level below top of casing: `' (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use'•+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the forth to the address in 24a
12.Well construction method Y L` above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test. air pressure 24c.For Water Suuuly&Iniection Wells: In addition to sending the form to
n(� ® /' the address(es) 'above, also submit one''copy of this form within 30 days of
13b.Disinfection type: i/1 71�J Amount:G ra� 0� completion of well construction to the county health deparhnent of the county
where constructed.
i
Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22-2016
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