GW1-2022-06169_Well Construction - GW1_20220701

1.W ontractorInf -motion:
•14:.WATER ZONES
Well Co tar are FROM TO DESCRIPTION
ft ft
r
ft ft.
NC Well Contractor Certification Number
CASIN�,(fo`r mnlii='usedweILs)08I.'II�?1R(if._.IIcahla•�:�::',:-::'•.'.:
Morgan Well&Pump, Inc. = FROM DIAMMTER THICIiIi'ESS MATERId•T
Company Name +1 ft- ft. 61/8/ m' sdr11 pvc
/ ��yyC 16.�R CASING 012•TIIBING:''eotfiermaZ closed-Iod' ?.`:.;'-.._• �'.; •',_. ' . .
2,Well Construction Permit#:3�V J�2 FROM TO DIAMETER TmcmgEss MATERIAL'
List all applicable well cons huc6an permits r e,wc,,Cow4v,State,Pa lance,etc.)• ft ft m•
3.Well Use(check well use):, fL ft. m•
17_-sCREEN',::: _•. . , .i;.
Water Supply Well: VROM TO DIAMETER' SLOT SIZE~ JTIRCKNESS rMATERIAL
Agricultural Ml MDnicipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) (Residential Water Supply(Single) v,
17ndustriaUCommercial J Residential Water Supply(shared) :GRODT::,.
Ird ation FROM TO I MATERIAL Y Erdpia EMENTMETHOD&AMOIINT
Non-Water Supply Well: 0 ft 20 fL bentonite. poured
Monitoring DRecovory ft. ft
-Injection-Well:
ft ft
Aquifer Recharge K!Groundwater Remediation r. -
Aquifer Storage and Recovery ;Salim Barrier ''FR19:SMND/GRAVEL P9 CK MOf a ERL4 lie ;;.:= _- _' :-•' : O
ty FROM TO MATERTdr. YEYPLACEMEA''Trl2ETHOD,'
Aquifer Test 13Stormwater Drainage it ft
Experimental Technology OI Subsidence Control ft ft
;Geothermal(Closed Loop) Tracer ;zO.tiRU�LCIG.L'OG'(attaciidditionaislieetsifn`eces's
Geothermal(Heating/Cooling Retum) J Other(explain under#2_1 Remarks) FROM TO DESCRIPTION(color,hardness,soi]/rock type,groin size,etc)
c ft ft .
4.Date Well(s)Completed: !.+(/Well ID# I5 ft. JA ft
5 Il Loca11on: c ft ZA
f • J r /l` ft �� ft
Facr7ity/Own Nffam�•e Facility M#(if applicable) �J R
cal Address,City,and Zip ft ft 'U-- ?L_i
County Parcel I i-6 cation No.(PIN)
Of1iJi ir':si CCl %i G�ti;:'„,j Chili
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �; /t {)i j
(ifwell field,one 1a��is sufficient) � o _
3�.55 -N i/ .
6.Is(are)the wells) Permanent or OTemporary S;lna e f rtified Well Contractor •Datt
B nine ris farm,I hereby cerzrfy that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well• QYes or YINo wrt 2 ILA C 02C.0I00 or JSA NCAC 02C..0200 T7ell Construction Standmde and that a
Ifrhis is a repair fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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'of wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: L+�d (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths)rdiar ent(example-3 n20D''and 2@I00D 24a.cons For A to the ls: Sfollowing;b
10.Static water level below top of casing: 35 (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 Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 0"�-(, - above,also submit one copy of this form within 30 days of completion of well.
J
(Le.auger,rotary,cable,directpuslm,etc.) construction to the following: -
EWATEMUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water SuDDIy&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
typ1� _ Amount• QT,r completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised2-22-2016