GW1-2022-06249_Well Construction - GW1_20220701

1.W ontractor mation:
•14:WATER ZO11M - •. •...._._:.:;
Well Co for are mom TO DESCRIPTION
ft $ft ft
NC Well Contractor Certification Number � 'I5:OUXER:CASIfiG,(for mnlfi=rasedSvens)ORM�ER(If'a'licable)'•y:�::'.:,::'•.`.:
Morgan Well &Pump, Inc. = _F_R0_M___j TO I DIAMETER THICSNESS MATERIZ
Company Name +1 4 ft 61/el m' sdt21 pvc
ent3" c1o'sed lod
16.�Ft CASING OR.•TUB12iTG:' ermal
2.Well Construction Permit4: 2Z O�� FROM TO DIAMETER TMC=S MATERIAL
List all applicable well construction permits'(ze UIC,County,State,Variance,etc) ft ft. n.
3.Well Use(check well use): f, ft in.
V
pply Well: 17_"SCREEN',_:.: =::. .�;'••> 4 '.::-;..:�•: .:..�.: :;.. .: '•
FROM TO DTAMETER. SLOT SIZE TAiCFQPESS MATERLIL.
tural lMunicipa]/Public ft ft in.
mal(Heating/Cooling Supply) ®]Residential Water Supply(single)
_ ft fc in.
1 Industrial/Commercial !Residential Water Supply shared -_•,•.,. ,:,;.- _ _
PP Y(shared) ;:78:GROIIT.
[Aq
tiOn FROM TO `MATERIAL Y E IACi.'rvrrrra7•METHOD&AMOIINT
ater Supply Well: o ft 20 ft bentonite• poured
toring Recovery ft ft
n.Well. ft ft
er Recharge nI Groundwater Remediation , . __ .. . : •.
.'19:SAND/GRAVEL• A:CTC If a"licif e
er Storage and Recovery SalinityBartir FROM TO MATERIEL E1V2LACLn2ENT11y=OD
er Test QiStormwater Drainage ftmental Technology OSubsideace Control ft ftermal(ClosedLoop) MTraru :20.DRII.LING.LOG'(attictiaddition'sls7eetsifFROM TO ft
rmal(Heating/Cooling Return) -i Other(explain under#21 Remarks) d �� '
ft
4.Date Well(s)Completed: s Well ID# S
5a.Well Location: ffi ft
Facility/Owner Name Facility ID;#(if applicable) fL fL l
x6ja Z259) it. ft.
(Ph�ysii�cal Address,tC�i(M and Zip 71 ft ft
County Parcel Identification No.(PIN) JUL 0 1
ZUZZ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Unit
CiifwCellfield,one lat/longissufficient) �j r� �]q rt.tl•S;^>Qt:�
0. Y� l 1 2Z72::��
/,_ .
N W y �d Z 7✓
6.Is(are)the well(s)*Permanent or MTemporary S10-115.4
f rtified Well Contractor Date
Bo is form,I hereby ceitfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Xes or #@No w C 02C_0100 or,15.4 NCAC 02C,0200 Meg Construction Standmds and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofihii record has been provided to the wall owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'ofwells construction details. You may also attach additional pages if necessary.
drilled: . w SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 200 (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdijerent(example-3 t@200'and 2@100) construction to the following:
10_Static water level below top of casing:_ 40 (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: r 0.��L� above,also submit one copy of this form within 30 days of completion of well.
construction to the following:
Ci auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
` 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a_Yield(gpm) 6® Method of test air pressure 24c.For Water SuppIy&Injection Wells: In addition to sending the form to
the addresses) '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 constmtted_
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016