GW1-2022-06254_Well Construction - GW1_20220701

1.W ontractorW, oration I I
14:.WA.TERZONES : :. .-• >...-,: .: :;
Well Co tar are FROM TO DESCRIPTION
ft ft
� i r ft ft
NC Well Contractor Certification Number
(fo'15:OUTER_•GASIPIG, r rnniti=cased ive3ls) LIlVER OR (if'licable)•y:::`.:,::' .`._
Morgan Well &Pump, Inc. FROM TO' DIAMETER I TRICYINESS MATERIAL.
Company Name +1 ff ft 61/6/ m sd21 pvc
�J r/ti V� 16,II�2 CASING OE•TUBING."eotfierma7 rin'sed-lori' r
2.Well Construction Permit#: (,2— FROM TO DLUMMTER TEaCIQIESS r~1 MATERIAL '
List all applicable well construction jomnus'(Le.UIC,Cowgv,state,Ym7ance,etc)- ft ft. in.
3.Well Use(check well use):
ft ft. in.
Water Supply Well: 17_"SCREEN'„.; :,_. .`�.. ..:•=•.: =.• �'.::_;,.:�: : ::'
FROM TO DIAMETER SLOT SIZE TMCOMS I MATERIAL.
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) ®fiResidential Water Supply(single)
I IndustriaUCommercial _Residential Water Supply(shared) 77
l lni ation FROM I TO MATERIAL I EMPI.4CEMENTMETH0D&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite• poured
'Monitoring DRecovery ft. ft
-Injection.Well
_I ft ft
Aquifer Recharge DI GroundwaterRemediation
m Bawer SAND/MUVFL'PACK if a"hirable
Aquifer Storage and Recovery Sali
tY FROM TO MATERIAL '.EMyLACEMENTIY=OD
Aquifer Test QlStormwater Drainage ft ft
Experimental Technology OISubsidence Control ft ft
Geothermal(Closed hoop) j3Tracar :2D.tiRILLING.I OG'(attaclisdditiiiusI sT?eetsneces' ):.. :•:'= :
Geothermal(HeatinglCoolingRoturn) I Other(explain under#21 Rematks) FROM TO DESCRIPTION(color,hardness,solyr"k type,grain size,ere)
O ft20 ft
4.Date Well(s)Completed: 12P Well ID# 2-o it.
O ft-
5
2- ft Well Location:
y� ft ft
�F11M�/Na�c///ilit�y�/.•••Owner Name �Facility
JD##r(ifapppliiccable) ft ;tee p (•"b r °i
ft ft �"� jm„b�..��'Fi,..$ A :.....r,.,.
z.
ysicalAddress,City,and Zip ft ft Jill
`t�22
UnT
h Parcel Identification No.(PUN)
Cann :9�✓^`-'
•-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ffwell field,one lat/long is sufficient) r�
-1 2 canon:/I!
N
6.Is(are)the well(s) Permanent or DITemporary Sign e f rtifed Well Contractor Da
g is farm,I hereby corn•fy that the weR(s)was(were)constructed in accordance
7.Is this a repair to an emdsting well: Dyes or 0No wulr ISAN C 02C.0100 or ISA NCAC 02C.0200 YPeV Construction Standards and that a
Iftl:is is are fill out known we➢construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 rernarla section or on the back of thisform. 23.Site diagram or additional well details:
8.For Gecprobe/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 I GW--1 is needed. Indicate TOTALNUMBER'ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 16to (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&t all depths myth&-ent(.,;m I.-3 200'and 2@100D construction to the following.
10.Static water level below top of casing: 45 (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 Infection Wells: In addition to sending the form to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (r` construction to the following:
(ie_auger,rotary,cable,directpush,etc.)
EYieeld
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method o£test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
typ Amount: ��67.1 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