GW1-2022-07281_Well Construction - GW1_20220809

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wellt�otpr e� I FROM I TO I DESCRIPTION
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NC well Contactor Certification Numbet
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Morgan Well&Pump, Inc. I DIA114ETERi TMC IWS MATERIAL
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ft 1 61/B/ m' sdr21 pvc
Company Name 2.Well Construction Permit �1o\�r� ,•s�-..�• �t,i:,•.,••' -
(!r 16.�ET It Ci1S]NG OZ2T[JBI1�G. eotlier`ma1'cIo'sed-too
#: FROM TO DLI.METER; THiCENESS MATERIAL
List all applicable well consnuctionpermirs'(ie UIC,Cow4v,State,Ymiance,etcr ft f R in.
3.Well Use(check well use): ft 'ft• in.
17--SCREEN',':.: ,, -'.a,,- '•'
W
ater Supply Well: Mom TO DUKETER I SLOT SIZE :^TMCIOMS MATERIAL
Agricultural 13Muaicipal/Public ft ft in. !'
Geothermal(Heating/Cooling Supply) ]IResidential Water Supply(single) f ft �•
J Residential Water Supply(shared) _
:iY8r GRODT: �''
bi,rigaticm FROM I TO MATERIAL - EbfpL-4CEMENTMETHOD&9MOIINT
Non-Water Supply Well: o ft 20 ft bentonite poured
t Monitoring Recovery ft ft
Injection Well: ft ft
_Aquifer Recharge [3 Cn-oundwatea Remediation r••. . .
;.19:SIND/GRAVEL'PA.CK tf a'iicablb '.
• 'Aquifer Storage and Recovery DSaliaity Bawer I FROM TO MATERIAL FMPLACEMENT METHOD
J Aquifer Test 13 Stormwater Drainage fr ft
Experimental Technology Oj Subsidence Control ft. ft
Geothermal(Closed Loop) 13Tracer :2D.DRILL¢7GSOG'(attach'sddition'alsheetsaecess'-j'a: ::'_+ -_
FROM TO DESCRIP ION color,hardness,soil/rock ty e, size,eta)
a Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) `
ft- ft
4.Date Well(s)Completed: well ID# u ft ft. `
s e11 Locatia : Z,p fIRA
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Facili /Owner Name Facility ID#(if applicable) ft• ft J 9
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`1 CV ft ft AUG
ical Addre1ss,City,and Zip Ir t ft. M
'RlMARTCC'- _ `•i _ �' �.x _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Crfwell field,one lat/long is sufficient)
22. ration:
N W
6.Is(are)the well(s)&Permanerrt or OTemporary Sig-ma a Contractor Daft
By o 'ig tl' arm,1 hetebv cer4ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an well; 0sting well; Yes or *No with ANCAC 02C.0100 or 15,4 NCAC 02C•.0200 Well Construction Standm-ds and that a
If this is a repair fill out known well construction ieiformation and explain the natw•e 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'of wells conshuction details. You may also attach,additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I bc) (ft) 24a. For All Wells: Submit this form'within 30 days of completion of well
For multiple wells list all depths y-different(ermnple-3Qa 200'and 2(Qa 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 casbrp usg"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to'sending the form to the address in 24a
t above,also submit one copy of this form'within 30 days of completion of well
12.Well construction method: r o"'r L1
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS,ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) X 1_ Method of 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 fomr within 30 days of
13b.Disinfection type • Amount: completion of well construction to the county,health department of the county
where constructed
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Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 222 2016