GW1-2022-07328_Well Construction - GW1_20220809

1.Tolltractor C lufommationcv
QCfQ (J
aiise. 14:.WATERZONES
XAPM Ta DESCRIPTION r
Well Contractor Name ft ft
�J�✓o r ft. tt. f.
NC well Contractor Certification Number 15:OUXER:9ASING,(fnc multi-rased We 0R_
Morgan Well&Pump, Inc. - FROM To' Dran�TFst ' THICIfiYEss MATEPJA
+1 R ft 611B/ sd21 Pvc
Company Name / / ,:
/v^ l/.Jl 16.`Il�II�tER CASIIQG OR•TQBIlzG: 'eotlie'rmalr.Ip'sed-mod Drenre.rau THICI�TESS
2.Well Construction Permit#: FROM TO MATERIAL
Liar all applicable weII constructianpermirs'(ie.UIC,Comfi,State,Variance,etcf
ft ft
3.Well Use(check weII use): M ft
17--SCREEN'.
Water Supply Well: FROM TO DIAMETER+-SLOT SIZE THICKNESS I MATERVIL.
Agricultural r1jMunicipaLTublic ft ft in.
Geothermal(Heatiag/Cooling Supply)- IResideniial Water Supply(single) ft ft in.
Industrial/Commercial residential Water Supply(shared)
•Irrigation FROM TO Ivre r�ureT. J F.MyI..4CnaNTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentanite Poured
Monitoring Recovery ft ft
Injection Well: ft ft
Aquifer Recharge (GroundwaterRemediation
.19:SEND/GRAVEL•P9 Cg rf a `licable
'Aquifer Storage and Recovery DSalinity Baaier FROM TO • ft MATERit,L - Eilti?I,ACE[�iZT METHOD
90e.therm.l
Aquifer TestQlStommwater DrainagefiExpechnology ©1Subsidence Control ft ftGeothermal(Cloed Loop) OTracm :20.MRnMNG.IAG(atisEF ddit!60 heetc�faecess T =sFROM TO DES PTIONcolor,hardness,soil/rock e,grninsize,etc)
(Heating/CoolingReturn) �Other(explain under#21 ) ft ft
. v
4.Date Well(s)Completed:/�` Well M# ft / ft
Sa.Well Location: r+— b ft p ft
�'S�n:(cr r yoYT 6 ft. E ft 7 4_AA1
11
Facrli / wnerName Q FacilityID#(ifapplicable) ft ft.
D� �G cr ft ft `
Plrysical ess,�p ft ft
County Parcel Identification No.(PIN)
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwr1ild, ongiss cient) r} n�� 22.Certification: !n# r�;:at_. , :'i.:... >:'g Uni!
.Jrf ' UX I
6.Is(are)the well(s) Permanent or ©I(Temporary Sigoahue of Certified well Contractor Date
vvA By sionino this form,I hereby ceKify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or 4No wish ISANCAC 01C.0100 or ISANCAC 02C•.0200 PYell Construction Standards and rhaf a
If this is a repair;ffl out kno wn well construction information and espldn the nature of the copy ofthis record has beers provided to the i wII owrrer.
repair under#21 remark section or on the bark of this form
• 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed--Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTALNUMBERbfwells construction details. You may also attach adtiitionalpages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �vU (ft) 24a For All We11s: Submit this fosm within 30 days of completion of well
For multiple wells Ilst all depths ifdifferent(example-3@,200 2Qa 100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 r L` construction to the following:
(t.e.auger,rotary,cable,directpush,etc.) j
' Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY'??ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a_Yield(gpm) Method of test: air pressure 24c.For Water SuDDIy&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fors within 30 days of
13b.Disinfection type 50vl Cr Amount: completion of well construction to the county health department of the county
�" � where constructed.
Form Gw-1 North Carolina Deparbnent ofEnvironmental Quality-Division of water Resources Revised 2 22 2016
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