GW1-2022-06285_Well Construction - GW1_20220608

1. foractorInform_Von: I I
Ail T�8j
14:.WATER ZONES:'. :I--• ,..�.:• .•
Well Conffiactor.Nalpae FROM TO DESCRIPTION
ft ft !
�2Z Aft ft �
NC Well Contractor Certification Number
15;OU2'ER;CASING,(foc multi=dasea'wells)O 2LINER(if Bcatle'-s
Morgan Well &Pump, Inc. FROM T DIAMETER THICEATESS MATERTdI.
Company Name
+1 ft ft 1 61/6/' in' sdt21 pvc
,.
IC'I NER CA.MG OR-TUBING eatiierma7 rlo'sed loo'
2.Well Construction Permit#:_ Z FROM TO DIAMETER THICKNESS '. MATERIAL- ^
List all applicable well construction per !UIC,Cowgv,State,Ymiance,etc) ft ft in.
3.Well Use(check well use): fr j in-
VAgdcultural
upplyWeI1: 17.-SCREEN', -.. `_:. .`•�: .:•"•._:;;:::.•t• ;..: :.':::,�.' ::.. .:::` .=r
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
EDMunicipal/Public ft, in.
t ermal(Heating/Cooling Supply) f (Residential Water Supply(single) ft ft in•
l l/Commercial i Residential Water Supply(shared) GROUT:;
]Itri ation FROM I TO MATERIAL - MY21ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft ft
Injection.Well: ft ft
_J Aquifer Recharge DGroundwater Remediation 19.��/GRAVEL'PACK rf a"licatile "'• '
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT(METHOD
i Aquifer Test Q1Stormwater Drainage ft ft
1 Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :2B.DRILLING.L'OG'(attich additional slieetsjf i ecess-T:.
1 Geothermal(Heating/Cooling Retain) i Other(explain under#21 Remaeks) FROM TO DESCRIPTION(color,hardness,soil/rock ty e, n size,etc.)
r c O .f` ' D ft
brawin
4.Date Well(s)Completed J--�� Well M# ft 13 d ft
Sa.Well Location: 3 oofl
ft ft
acilrty/Owner Name Facility ID#(if applicable) ft ft
4� ��n���C lstne yJ D�C,286JS ft fc ;
Physical Address,City,and Zip ft ft
County Parcel Identification No.(PIN) rVe ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ate'
(ifwell field,
on�e`lat/long is sufficient)
-N C7�. W 22_certification:
4!!�L 2"� S' 3/ AP-7,
6.Is(are)the well(s)MPermanent or 13Temporary Sign o ertified Well Contractor Date
By .71
ri o is form,I hereby certify thai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or INNo w r IS CAC 02C-OI00 or ISA NCACI02C,0200 Well Construction Standards and that a
If Zhis is a repair,fill out known well construction hiformation and explain the nature ofthe copy of is record has been provided to the well owner.
repair under#21 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 orwell
construction,only 1 GW-1 is needed. Indicate TOTAL NUIvIDER'of wells construction details. You may also at additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths y'dierent(example-3 00'and 2Q100) construction to the following.
10.Static water level below top of casing: V (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: L�
above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.)
construction to the following:
LFOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
air ressure
Yield(gpm) � Method of test: P 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
Disinfection typ : Amount• completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of EnvironmentalQuality-Division of Water Resources - Revised2-22-2016