GW1-2022-07300_Well Construction - GW1_20220809

1.'Well Contractor Information: I ,,
•14:. ATF.R ZONES :: r
Well Contractor ame - FROM TO I DESCRIPTION
ft ft
NC well Contractor Certification Number
15:OUTFR:CASING,fo"r mnlfi rasedwPIls 02 L713L?t(if_ licahle ` :.
Morgan Well &Pump, Inc. FROM TO' I DIAMETER I THtCMgESS MATF.R1,4.
Company Name +1 R' ft 6 11B1 k in- sdr2l pve
�%7 /� 16.�II�TEI2 CASING OR•T[JBTItG: 'eotiier'ma7clo-sed-lod' .':;.":..i• '.:�':`•.`••'
2.Well Construction Permit#: $ ( FROM TO DIAMETER THICFNESS MATERIAL
List all applicable well construction permits•(Le UIC,Caauv,State,Variance,etc-),
ft fL in.
3.Well Use(check well use):
fL ft ! in.
A, !
ater Supply Wen: 17--SCREEN'.,:. .' C - .`�,'•-:•`_ ?:.. �:..r' :'iiG._�.'n:;.:. .:=:`
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
Agricultural QMunicipal/Public ft ft in
Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft ft in I
Tn3ustn Commercial J Residential Water Supply(shared) _-:,. -_•,-., _ _
:.18:GRODT
'i.i ation FROM TO MATERIAL - EMpL4CEMENTMETHOD&.4MODNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring C3Recovery ft ft.
Injection Well:
Aquifer Recharge Qj Groundwater Remediation D
'Aquifer Storage and Recovery Qi(Salinity Barrier FROND/GRAVEL PACK MATERIAL
- FhOLA. =OD
Aquifer Test. OStormwater Drainage ft ft
_Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) QlTracer :20,M. RMUNG.L'OG attacli'addition'ilsSietijfiiecess"O'-- ^:•:=
Geothermal(Heating/Cooling Retain) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cola, ardnen,soil/rock type,grain size,etc)
ft J#k
4.Date Well(s)Completed: Z `3-1—well m# s ft ft IArc
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Sa.Well Location: ft 6 9fl ft ��C� 1_C/
V C/ A Qcn1111 I I0Z 070 ft ft
Facility/Owner Name Facility ID#(if applicable) ft fL p
I a�3 s�>�I ,�d ft. ft. /
Physical Address,City,and Zip ft ft A IJ r 0 9 ?072
bA601A . >::''' ,.:.'.;^--;;.:' 'c:_s,.}:.:. -
If1fCir3SiAll(flit)
County ParcelIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sufficient) 22.Certiflca'on
35 .gy89 -N gl.3s a 3-7 W 7-/,?—ZZ
6.Is(are)the wells) ermanent or j (Temporary Si ture of Certified well Contractor Date '•
���`���"' By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is Ibis a repair to an existing well: ©Yes or%I No with ISANCAC 02C.0100 or 15..4 NCAC 02C.0100 Well Construction Standards and that 4.
Ifthis is a repair;fill out known well conshuctian information and explain the natty-e of the copy ofthii record has been provided to the we11 owner.
repair under 411 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 construction details. You may also attach additional pages if necessary.
drilled' Q//�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V V (ft-) 24a. For All Wells: Submit this form'within 30 days of completion of well
For multiple wells&I all depths if different(ezantple-3Q200'and 2 100) construction to the following.
10.Static water level below top of casing: `/ y (ft) Division of Water Resources,Information Processing Unit
Ifwater level is above casnrg,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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 fbim within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLX WELI�rtJNLY• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) A Method of test: air pressure 24c.For Water SuDnly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of water Resources Revised 2 22 2016
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