GW1-2022-06170_Well Construction - GW1_20220701

1.W ontractor Inf tion:
14:.WA.TERZONES ;
Well Co for =me FROM TO DESCRIPTION '
ft ft
ft ft
NC Well Contractor Certification Numbet
i '15:OUTER CASTPIG',(foi•mniti=ragedwiIls)ORI,II�R(rfa'licahle' :�::',:'.::'•."._
Morgan Well&Pump, Inc. FROM I DIAMETER THICKNESS MATERrna
Company Name +1 ti• ft 61181 rn' sdr2l pvc
FROM FR G O&•TDBIAME eotlier�aZ cl IC10lod' :•:
2.Well Construction Penmlit#: j�'J FROM To DIAMETER Tr�cl�tEss ~ MATERAL"
List all applicable well construcdon permits(e.U7C,Cowgv,State,Yarianee,etc.)• ft in.
3.Well Use(check well use): ft ft in.
jAgdcultural
r Supply Well: 17_-SCREM, �.;'•=•`_.:_::::'r•: ::: '•' •:-'..:=,:'i':-.-: n:;.:. :
�{ KGR
DIAMETER SLOT SIZE .TETCKNESS MATERTAL.
Water
L�--'tMunicipal/Public ft. � in.
thermal(Heating/Cooling Supply) Residential Water Supply(single)
stmiaUCommercial !Residential Water Supply(shazed)
1 Iui ation MATERIAL EMPL_4CEMFNT14fETHOD&AMOUNTNon-Water Supply Well: ft' benionite- poured
Monitoring Recovery ft.
Injection.Wft_!Aquifer•RechargeI Groundwater Remediation .L'PACK xf a'licible :.;:r :_ ., -.
'Aquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL EMPLACEMENTiMN 01)
Aquifer Test OStormwaterDrainage ft ft
I Experimental Technology Subsidence Control ft ft..
Geothermal(Closed Loop) O Tracer :ZD.DRILLING.I OG attar]isdditiorisIslieets.ifaecess -_
FROM TO ? DES PTION(color hardness,soilirock type,grain size,etc)
r Geothermal(FIeatinglCooling Return) /�_ Other(explain under#21 Remarks) R Yee-
4.Date Well(s)Completed: (� 22 Well M# �S•. R 1
Sa1y�
Well Location- ! ZO ^
C��main 3 ft ft 1'*&yvLt_6
Facility/OwnerN�e Facility ID#(ifapplicable) ft ft
fL
E.'
P icalAddress,City,and Zip ftft.
County Pan elIdentifcationNo. IN) �fl' -'*r,,':.n c�__
5b.Latitude and longitude in de.-rees/minutes/secands or decimal degrees:
(ifwell feld,one lat/long is sufficient) 2 er cation:
345' 12 N W 7 LX-
6.Is(are)the wells) Permanent or OTemporary Signa e f rtifed Well Contractor -Date /
B o ring is form,I hereby cerix•fy that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or *NO wrtlr 15A C 02C.0100 or 15.1 NCAC 02C:0200 Mell Construction Mandy ds and that a
If this is a repair,fill out faro wn well construction idformation and explain the nature of the copy of thii record has been provided to the well owner.
repair under 421 remark•section or on the back oftlus form 23.Site diagram Or additional Well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constriction,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; ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multi wells list all depths ifdiferent(erampl&3@ 00'and 2@I00� construction to the following.
10.Static water level below tap of casing: b (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61.7
11.BorehoIe diameter: 6 (in.) 24b.For Injection'Wells: In addition to sending the farm to the address in 24a
12.Well construction method:�- r L� above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.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 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Water Supply&Injection Wells:Iniecion 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 typ Amount completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016