GW1-2022-07326_Well Construction - GW1_20220809

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I.Well Contractor Information- h
7QCf Q1-� �',1guSe, 14:,.WATERZONES : ':: f.
FROM TO DESCRIPTION
Well Contractor Name � � fLI ,
NC Well Contractor Certification Numbet
IS:OUxFR:qASINO,(focmn114=raseawins)b%L" %R
Morgan Well& Pump, Inc. FROM To DIAAc reR TMCMMS I MATERIAL
Company Name +1 ft. 6 1/6/ sd,21 pvc
ft
16:`II�II�I2 CASII�TG OR•TQBIlYG: 'eotlier`mal'clo'sed-loo' ?.�:.:'�..e•<.:::'•:.:': ..
2.Well Construction Perm V: J FROM To DIAMETER THICKNESS ASATEP.IAL
List all applicable well consituctionpermits'(e UIC,Colaty,State,Yaiance,etc} fL ft in.
3.Well Use(check well use):
ft ft in.
Water Supply Well 17 sCRE>N'._ ;. .' =`:.'._::::,_ •;•:�; ',::_;..t�::`.;::,.:�::.:. .: -:
mom TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL-
Agricultural Muaicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
I lndust ial/Commercial E3Residential Water Supply(shared)
inigation I FROM TO MATERIAL EMPL-SCR?&ENTMETHOD&AMOUNT
Non-Water Supply well: 0 ft 20 fL bentonfte poured
Monitoring DRecovery M ft
Injection Well:
Aquifer Recharge tGroundwa`tmrRemediation ft ft
Aquifer Storage and Recovery OSalinity Bauier oS�ND/G TO RAVFS'Yd Cg MATERrIaAtile ~;:"Eil�LACEMEhT l2ETJ�OD
i Aquifer Test DStormwater Drainage ft ft
I Experimental Technology Di Subsidence Control ft. ft
Geothermal(Closed Loop) OTracei :2D.�RILIOr'GS OG'(attach'sdditiotial sheetssfaeces's' :{' <a :e.•.:
FROM TO DESCRIPTION(eolor,hardness,sdilrock e, ' sire,etc)
I Geothermal(Fleating/CoolingRetarn) Other(explain under#21 ) fL
4.Date Well(s)Completed: ✓� Well ID# fL
Sa eIl Lo fio VR ft
as ft (� ft re^
Facility/ wM Name acilityID#(ifap 'cable) A> R W ;~ fA^,
`1�e Gvft.
PlrysJ'f� /d7dr�ess,City,and Zip //J 1 ft. fL � U y
1 V_-�/yW/ ?j V 4�d3
(
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7 n,. t
(Ifwe�ll field,one lat(/long/is sufficient) 22•Certification' D�eJQii50'
- Ji VGon
� 1 I -N . b y W \v�l
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6.ls(are)thewell(s) Permanent or Oi Temporary Signature of Certified Well Contractor Date
By signing this form,1 hwre cett•f,chat the weg(s)was(were)constructed in accordance
7.Ls this a repair to an existing well: !J Yes or*o with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
9 this is a repair fill our known weD construcSon information and explain the natw-e ofthe copy ofthis record has been prov ded to the well owner.
repair under 421 remarhx 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 bf wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 560 —(ft-) 24a. For All We ls: Submit this form within 30 dayt of completion of well
For multiple wells Psi all depths irdi$erent(example-3Qa 200'anl22@100) construction to the following:
10.Static water level below top of casing: y (ft-) Division of Water Resources,Information Processing Unit,
If—ter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
II.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
. } L above, also submit one copy of this form within 30 days of completion of well
to
12.well construction method: 1 construction to the following:
(-e.sage,rotary,cable,directpush,etc.)
WELLS-ONLY: Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL
1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) / Method of test: air pressure 24c.For Water Supply&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:gCrcnc�I a r' Amount: b completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Ik Revised 2 22 2016
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