GW1-2022-05831_Well Construction - GW1_20220609

1.Well ttractor Inf matt n:
•14:. ZONES -
Well Contract a FROM T 1 DESCRIPTION
NC Well Contractor Certification Number ft
� '15:OUZ'ER,CASING,fnc multi-raked webs o�2I:II�rElt if a'licahle':3:�::'.:,::' .`.:
Morgan Well &Pump, Inc. FROM T DIAMMTER I THICams MATERIAL
Company Name +1 ft ft 61/8/ I m' sd2l pvc
16:11MR CASING OR-TVBNG. •edtliermal closed-loo i.
2.Well Construction Permit#: W FROM To DUMETER THICENEss •MATFitIAI',
List all applicable well construction permits'rz.e.WC,Canty,State,Variance,etc.)- ft ft• in.
3.Well Use(check well use):
ft ft in.
FWaterupply Well: FROM TO DIAMETER SLOT SIZE TEfrcw Ss MATERltural C5MunicipaVPublic ft ft in.
ermal(Heating/Cooling Supply) ®�Residential Water Supply(single) ft ft
n ommercial U Residential Water Supply(shared) .,•._, -
:;YB:GRODT.
fN
tion FROM TO MATERIAL - EMPIACEME Tr.mTHOD&-4MOIINT
afer Supply Well: 0 ft 20 it bentonite poured
oring Recovery ft. ft
n.Well: ft ft
er Recharge Cn'oundwaterRemediation
er Storage and Recovery n 19:SAID/GRAVEL'PAGK tf a p cable,Salim Barrier PROM TO MATERIAL EMPLACFMENT METHOD
er Test OStormwater Drainage ft ftmental Technology Subsidence Control ft ftermal(ClosedLoop) DTracer :20.tiRILLING.IOG'attachadditionalslieedifrmal(Heating/Cooling Return) 3 Other(explain under#21 Remarks) FROM ro ESCRIPTION(colo,hardnrss,sotllroek n 0 ft ft
4.Date Well(s)Completed YL-1 Well ID# 1 D. ft. Lj ft
Well Locatio ft ft {.
tI fft ftI;Y?A
Q.YbJA
Facility/O Name (mil Facility lD#(if pplicable) ft ft.
5 1, ft ft
Phy�siccaal`A'ddress,City,andZi ft ft L:1
.�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: m'"on Proceaft
UrA
(ifwell field,one lat4ong is sufficient)N , ��� W 22_C cation
35 ( 3y <UC- g 7�> & ZZ-
6.Is(are)the well(s)gPerranent or QlTemporary Sign e fC ' ed Well Contractor Da
tK
By signing th orm,I hereby cwltry that the well($)was(were)constructed in accordance
7.Is this a repair to an existing well: L71 Yes or J%No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repaU•,fIII out known well construction 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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: l (ft) 24a. For All Wells: Submit this form within 30 day8 of completion of well
For multiple wells list all depths ifdifer•ent(ex=ple-3 eQr 200'a:d 2@100) construction to the following.
Lin
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 2 7699-1 61 7
11.Borehole diameter: 6 (in.) t 24b.For Iniection Weill: In addition to sending the form to the address in 24a
Well construction method: QY LI above, also submit one copy of this'form within 30 days of completion of well
12.We auger,ll construction to the following:
(Le.' rot ary,cable,direetpush,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniectio i Wells: In addition to sending the form to
``44�� n the addresses) 'above, also submit lone copy of this form within 30 days of
13b.Disinfection type: �WlXV1lU Amount: ( 62 completion of well construction to the'county health department of the county
where constructed.
i
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016