GW1-2022-07298_Well Construction - GW1_20220809

1.Well Contractor Information:
CI%Y,5 Dort ci •14:. ATER zolvEs
Well Contractor Name I FROM TO -I DESCRIPTION
NC Well Contractor Certification Number 'zV ft Z"g/ ft
15:OUTER,(ASING,(foc multi=rased sv%Ds b_Lu�,R rf-'Triable
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICKivEss MATERIAL
Company Name +1 & ft. 61/8/ sdr21 pvc
' 16"11T�R CASIl�TG 012•T[TB1i�G. 'eottiermalclu'sed-Ion' � -
2.Well Construction Permit#: FROM TO DIAMETER THEICIGMS MATERIAL
List all applicable well construction permits(r.e•U1C,County,State Vw iance,etc)• ft ft 6 in.
3.Well Use(check well use): R t- in.
JEra ,Srupply WeII: FROM TO D SLOT SIZE THTOOMS MATExrAL.
ltural MMuuicipat(Public ft ft in.thermal(Iieating/Cooling Supply) �lr Residential Water Supply(ogle) ft.E stn Commercial J Residential Water Supply(shared) :1Y8r GROUT.::•.
r
'on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ter Supply Well: 0 ft 20 ft. bentonite poured
oring Recovery ft ft
Well:
� ft ft
r Recharge MJ amundwater Remediation
r Storage e and Recovery ..19:SAM/GRAVEL'PACK(If a•llcabre
ag ery Oi Salinity Barrier FROM TO MATERIAL Ei1ffLACEMENT i1N=OD
r Test Q1StormwaterDrainage ft ft.
ental Technology Subsidence Control ft ftrmal(Closed Loop) OTracerrmal eating Conlin Return) J Other FROM TO DESCRIPTION(color,hardness,soil/rock size,etc
4. (II g ) (explain under#21 Remarks) O
4.Date Well(s)Completed: -/ Z2 Well ID# ?J�. ft �� ft. fo ✓l
4
c'
5a.Well Location: ft Q f.ft ft.
ra �j OYt
Facility/ Name Facility ID#(if applicable) ft. fL
fL ft.
Physical Address,City,and Zip ft ft.
{ r.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient)
22.Cer'fication:
3S.15IV N �D=�i' � W 72 2Z
6.Is(are)the well( Permanent or [3Temporary Sigr,a of certified Well Contractor Date
By sigi ins this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing weIl: ©Yes or No with 15ANCAC 01C.0100 or ISA NCAC 02C,0200 Mell Construction Standards and that a
If thir is are fill out(mown well construction information and explain the nature of the copy ofthis record has been provided tothe Kell owner.
repair under#21 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 NUNMER'of wells construction details. You may also attach additional pages if necessary.
drilled. SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: �d (fL) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths j'dii ferew(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Ifo (ft) Division of Water Resonrces,'Information Processing Unit,
gwater level is above casnro 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
Ir t above, also submit one copy of this four within 30 days of completion of well
12.Well construction method: LI
construction to the following:
(Le,auger,rotary,cable,directpush,etc.)
[113b.
OR WATER SUPPLY WELLS,ONLY' Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,�Raleigh,NC 27699-1636
a.Yield(gpm) CJ Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
` c the address(es) 'above, also submit one(copy of this form within 30 days of
Disinfection type: I-IL �� Amount• J2tsZ 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
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