GW1-2022-06243_Well Construction - GW1_20220701

�KLCQxCIl (CaW-1) I ForInternalUseOnly:
1.Well Contractor Information: `
.)?AV )0� J � •14:.1WATERZ0NES,'. - :: �.:%::':....`•':'..._:.::
Well Contractor game, FROM TO I DESCRIPTION
6 ft ft
ft ft.
NC Well Contractor Certification Numbet
•� '15:OU�ER_CASING,(io'rmniti=rasedweIls)O�tT�lTE12Ctf• 'licable)'=�:�::`.'.;:" .'._
Morgan Well & Pump, Inc. : FROM TO' DIAMETER THMILITEss MATERIAL
Company Name +1 ft.
�t! ft 61/8I m sdr2l pvc
j� /� 16.�ER CASING OE-TITB]l�G:'•eatliermal•cln'sed-rod`L:':.�-'=' '•S%�":,�"
2.Well Construction Permit#: i C(A/ 0 FROM To DIAMETER T111clslEss Mnr>urns.
List all applicable well construction permits"(t e.UIC,County,State, a iance,etc.)- ft• ft. ut t
3.Well Use(check well use): ft' ft. in.
Water supply well: 17_"SCREEN': •.: '::. -'• :• :,•:. ='. :_ :: :._r. ;.:. .:=`•
� FROM TO DIAMETER SLOT SIZE T13rCKNFZS TYIATERIAL
!.='1 .
!Agricultural Municipal/Public ft ft in.
1 Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft
I Inam—E -Commercial J Residential Water Supply(shared) 8:GROUT•::, -
Ird ation FROM TO MATERIAL EMPL4CEMENTM=IOD&AMOUNT
Non-Water Supply Well: o ft 20 ft- bentonite• poured
Monitoring Recovery ft. ft
Injection.Well: ft ft.
__I Aquifer Recharge f3 Groundwater Remediation
:.'19:SAND/GRAVEL'PACIC tf a"licab]e '.
Aquifer Storage and Recovery �Salinity Barrier FROM TO MATERIAL EMPLACEMENTtl9ETHOD
_'Aquifer Test 13Stormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.-nRTCSSNG.T OG'(attacit additional sheetsifnecess -j' :•: s
Geothermal(Heating/Cooling Retum) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sorUrocktype,grain size,etc)
a ft ft k\/✓l1. /j ff
4.Date Well(s)Completed:—z 6ell ID# q, . ft Z � 110-VIA, - t,
5a.WelllL/ocation: �} 01 ft I�J ft 81 t J G .al e)
j1/'2 /� Vl� ft ft (O
Facility/Owner NameE Facility ID#(if applicable) ft ft
It
ft
Physical Address,
/City,and Zip ft ft >` ;'Ili
Y�
County Parcel Identification No.(PIN) _ 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longissufficient) {fFiOii: :r l of^0u:3 Unh '
,� /^ 22.0 'caon: tt:"Qrr'�t}Li
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor -Date
�l By signing this form,I hereby ceritfy that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: M Yes or ONO with 15.4 NCAC 02C-0100 or,15,4 NCAC 02C-.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well consU uc4on information and explain tJie nature of the copy ofthii record has been provided to the well owner.
repair under 421 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"Ofwells construction details. You may also attach additional pages ifnecessary.
drilled:_ t1 1 / SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: JI �J1 (ft-) 24a. For All Wells: Submit this foim within 30 dap of completion of well
For multiple wells!list all depths ifdiferent(example-3 20000'`and 2@100I construction to the following:
10.Static water level belowtop of casing: C�! (ft) Division of Plater Resources,Information Processing Unif,
Ifwoter level is above casino use"+" 1617 Mail Service Center,Raleigb,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: LAIr L( 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 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SuDuly&Infection Wells: In addition to sending the form to
type:_ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection e: I ` / Amount: completion Of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016