GW1-2022-07272_Well Construction - GW1_20220809

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NC Well Contractor Certification Narober
'15:OU�'ER.•GASIfiG,fni•riiniti�..eil sseDs)012 L�'ER Cti"_.licahle.y:�::`.:•::'•.'.:
Morgan Well&Pump, Inc. I DIAMETER TSICKiVESS MATERTdr.
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Company Name +1 102 ft 61/a/ sdr21 pvc
�`+����� 16"IDIIQIIt CAiSIIQG O&•T DXAG. M
FROM To I ilierma7 clo'si:d-Iri ""M?groin'
2.Well Construction Permit#:_y DIAMETER TFIIcrsS•
Iasi a➢applicable we➢construction permits CorouV State,Ymurnce,etc) R R !fn
3.Well Use(check well use): ft ft in.
1VSCREEN*,_'.: _j•-;..,,. ;.i r'.:�•''=Y--.;. : "•' ...:
Water Supply Well: AROM TO c DLIME 'SLOT SIZE. TAICNTBSS MATERIAL.
i Agricultural QMunicipaLTublic ft fL in. I
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Geothemnal(Heating/Cooling Supply) ffiResidential Water Supply(single) ft fr-
in i
i ommercial _I Residential WaterSupP y(sha red) -
:;18:GROUT•: --�`''v i- - - '
•on FROM I TO I MATERIAL) RWiACENMgTM=OD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- bentmb. poured
Monitoring Recovery ft. fL
Snjection.WeII: ft ft
I Aquifer Recharge []I Groundwater Remediation
I9:S /GMRL&V -PACK tf-...Iica6Ie ' C -' ;:':;:_':: . •.:'':_': '•::'•..,. C::
Aquifer Storage and Recovery OSalinily Bawer FROM TO MATERIAL - F�LACE[�NT aYfETHOD
Aquifer Test DStoimwater Drainage R ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) QlTracer ;20.DRU�rGS OG'(attac}radditional s2ieetsaf aeces "7:t'^''= - :. '
Geothemlal eating CooIin Retum J Other FROM To DESCRIPTION(calo,hardness soiUroek ippe grain sia eh)
e (H g/ gg tu� ) _� (explain under 421 Remarks) O ft 130
4.Date Well(s)Completed: l LJ—Lfwf/Well ID#/ 30. It
ft diitl-
Well'Location: I L 0 tt 45 ft
GS 5 it.it.1 qcx>f' c. tlz
Fact7ity/O Name FacilityID4 fapplicable) ft.
ft
l,�S_�c h�.vcan 'c�,r. •Y�1c�rs�,r►ll� NL � � =-� •
Pp!C icc.l�►Ad/\d�r/rss`,City,and Zip r/��/(,
2�1� ft ft �-- v
��li2_ V`\ ,/V '21E'RIPMARTIC'- - `.i-' -
County Parcel IdentificafionNo.(PIN)
Iflttiir'Yl�3lC1 Sb.Latitude and longitude.in ryTf>�.:�abL,1: Urthdegrees/minutes/seconds or decimal degrees: ✓; �
(well field,one laMong is sufficient) 2 cation'
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6.7s(are)the well(s) Permanent or Qli Temporary
Signa f rtified Well Contractor Date
e ing is form,I hereby c®fify that the wen(s)was(were)consmtcted in accordance
7.Is this a repair to an existing well: []Yes or *No wrth iSA C 02C-Oi00 or 15A NCAC 02C:0200 JVe➢Construction Standards and that a
Ifihis is a repair•,fi➢out known we➢construction biformadDn and ezplain the nature ofthe copy ofthis record has beetprovided to the well oxvrer.
repair under 421 remarks section or on the back ofthisform 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'of wells construction details. You may also attach additional pages if necessary.
drilled:_ 11
` SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: `�� (ft) 24a For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths ffdffferert(ermnple-33@200'and 2QI00) construction to the following
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,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
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: L! construction to the following:
(Le.auger,rotary,cable,directpusb,eta)
FOR WATER SUPPLE WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) Li Z Method of test: air pressure 24c,For Water Suuuly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fowl within 30 days of
13b .Disinfection typ ' Amount: Z OZ completion of well construction to the county health department of the county
where constructed
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Form GW-1 Nardr Carolina Deparhnent of Environmental Quality-Division of Water Resources ;. Revised 2 22 2016
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