GW1-2022-07329_Well Construction - GW1_20220809

Well C.Laq&anz� F80M TO DESCRIPTION
R
i ft ft I
NC well Contractor Certification Numbet
Li:OUTL'R•CdSlI�TG,(foi•mnlfi=Easedsee�s)b12L�3ER zfa'licahle'•a:�::'.'.::'•.'.:
Morgan Well &Pump, Inc. FROM 0' 1 DLU"MR TMCF"NESS I MATERM
+1 fL fL 1 61/8l In. sd21 pvc
Company Name
{•�/ n//O 16: TEitC9�SIl�TGOB•TDBIIiTG. "eottie'rmal'clo'sed3od"r:'1�''•a'<':; ': .
2.Well ConstructionPermitt 3 L5 2Z FROM To I DIAIYXM T�=KM MATMUAL-
List all &cable we➢construr�an a7n is L a WC,Camiv ft ft � in.
aPP� P (' Stale,Variance,etc)•
ft ft b•
3.Well Use(check well use):
Water SnppIp WeII: 1'z St3tEW'.:��.: _ .`�..-..:`: = ::�'r::.• ��� ��..:•�•-:::;•-.�•"�:;•.:.:::`•
FROM TO DTAMETFR`.' SLOT SIZE .TffiCTOZESS MATERW,.
Agricultural DMnnicipal/Public ft tt
i&-thermal(Heating/Cooling Supply) 1FResidential Water Supply(single) ft fc in.
Commercial J Residential Water Supply(shared)
GR ODT•.
,iiii ation FROM TO I MATERIAL - MaLkCEMENTD=n'n&AMOUNT
Non-Water Supply Well: o ft 20 bentonite• poured
Monitoring K3Recovery ft ft
-Injection.Well:
_Aquifer Recharge MCnoundwaterRemediation ft ft
Aquifer Storage and Recovery Ot Salinity Barrier TO YACg MAT RTAAlre ::. " .F MrLAC&M3WT`h=OD'
-Aquifer Test E)Stomrwater Drainage ft ft
_i Experimental Technology Subsidence Control ft ft
Geothermal(Closed 1ITracer :20.DI2IiS�TGSOG(afractiadditi6natslieefsafneces "�'.{;�`t € .'.'':- is
'Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM To DESCRIPTION(eclor,hardness so]/rock tp a size,etc)
C. aft. o � rcd. d►
4.Date Well(s)Completed: Laval,ID# o ft 3s art-
5 ,��Lorati 3S ft f
Facility/Owner Name FacDilyID#(if applicable) ft rt'
0001 top
- ;405�4 ft r�.
��, �n tm..
ft. ft
Pb.uicalA`ddresss,,City, ip
.7J�Al[l�A • �l� O3� •'ZL'RIZMARKR'-'::.<.`_::-%:"_ ;.... .:-...•:. _ - _ _,• 5
County Parcel Id— catim No.gIN) ^:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lai/long is sufficient) 2 cation:
3S ". 520 -N Sp.UO l6 W 7 5 ZZ
6.Is(are)the well(s)*Permsnent or OTemporary Sign a f rtibed Well Contractor Date
B gning is form,I hereby certify that the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or *No wuh 15.4 C 01C.0100 or 15A NCAC 01C.0100 FPe➢Construction Standards and that a
If this is a repair fill out known we➢cons&action i»formation and explain Die nature of the copy ofthis record has been provided to the well owner.
repair under 4111 remarks section or on the bark ofthisform
23.Site diagram or additional well details:
8.For GeoprobaMPT 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 `1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SI D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mu&iple'we11s list all depths f#-&&-ent(ezatnple-3@42 0'and 2 100)
construction to the following.
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the fog to the address in 24a
above,also submit one copy of this foil within 30 days of completion of well
12 Well construction method: 0 L` construction to the following:
0-e.auger,rotary,rabic,daeatpush,etc.)
E
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test air pressure 24c.For Water SuDuly&Infection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this foil wi`.bin 30 days of
typ Amount: completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Envimnment d Quality-Division of water Resources - Revised 2 22 2016
i