GW1-2022-07357_Well Construction - GW1_20220808

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NC Well Contractor Certification Nunibet
t '15:Or7?'s':R-G651TIG,(focmniti�eHvreIls)bRLTi�R ff's'licalile'-1:�:•.`.�.::••.'.:
Morgan Well& Pump, Inc. FROM TO' DIAMETER THICL�FsS MATERIAL
+1 ft. ft 611B1 I b' sd21 pvc
Company Name 1 I _
V +r,J� 16 II3aR G 012•TCTBTI�Cr. 'edtliermal closbd�oo ..
2.Well Construction Permit#/:- FROM I TO IDIAMETER =XNESS MATERIAL' ~
Zist a➢applicable well construction a•»its L e.WC,Cotmiv ft ft in.
aPP• P ( SYatG Variance,etc)•
IWell Use(check well use): fL ft in
I7."SCREEN.:.:: _ :...,. :•i,. ..-_• .:_t,- '. ...:
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THTCKTESs YmuTERIAAI.
J Agricultural QMnnicipa]/Public ft ff
a !Geothermal(Heating/Cooling Supply) APResideatial Water Supply(single) ft ft In-;
I bidustnal/Commercial J Residential Water Supply(sbared) 18:GROUT. - ° _ _ -
'pn FROM To ,MATERIAL E LACF NTMETHOD&.AMOUNT
Non-Water Supply Well: o ft• 20 ft bentonite poured
Monitoring ft ft
snjection.Well: R ft
_J Aquifer Recharge Dt Groundwater Remediation
• A ea Storage and Recovery t S :•19:SgLTD/GRAVEL'PACK tf a"7irrafifil'e ....�: '�::<:'.::_''::•.-•.:''�,�•:.'•.:'''= '�:.
quif g ery ©I almity Banier FROM TO � MATERIAL � EMPLACEA'l VT METHOD
J Aquifer Test QlStormwater Drainage ft
_Experimental Technology Subsidence Control ft- ft
t Geothermal(Closed Loop) �ITracer :20.TDRIILINGI OG'(aiiacliaddihon'sis}ieefsaeces' "7: ^!=s .' ',v i
Geothermal(Heating/CooIing Retlm) J Other(explain under#21 Remadcs) FROM To DESCRIPT ON(color,hardaeuss sail/roektype
4.Date Well(s)Completed: 4Z Well M#/ ,S ft �S
52.Well Location: 35 ft I�o ft
p ftft
Facnlity/OwnerN a Facility M#(ifapplicable) ft ft
Physical Address,City,and Zip ^ ft fG
County Pan:elIdentiticaiionNo.(PIN) UM
lft•YJf7i�a�tC1 r�fOC.x'1�r.'lt+�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,eBan
ff well field,one lat/long is sufficient)
N 2 er ration:
6.Is(are)the well(s)*Permanent or Temporary Signa lined Well Contractor Date
B o vna is form,I he;
cerb y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONO i4015A C 02C.0100 or 15ANC4C 01C.0200)=Pell Consnancdon&-1 ds and that o
If this is a repai fill out(mown well cowhwadon hiformation and explain Me nature of the copy ofthis record has been provided to the well aw•ner.
repair under 421 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 TOTALNUMBER'ofwells construction details. You may also attach additional pages ifnecessary.
drilled
- +L SUBMITTAL INSTRUCTIONS .
9.Total well depth below Iand surface: w (ft) 24a For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells&I all depths lfdifereni(exmnple-3 c@200'and 2Q100) construction to the following.
10.Static water level below top of casing: 4 v (ft) Division of Water Resources,'Informstion Processing Unit,
Ifwoter level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) f 24b.For Injection Welk: In addition to sending the form to the address in 24a
12.We construction method: L` above,also submit one copy of this form within 30 days of completion of well
(-ie.auger,rotary,cable,directpus4 etc.) construction to the following:
EYield
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,';Raleigh,NC 2 769 9-1 63 6
i Method of test air pressure24c.For Water SuuDly&Iniection Wells: In addition to sending the farm tothe addresses) 'above, also submit one copy of this form within 30 days of
typ Amount.• Z� oz, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofHnvironmental Quality-Division of Water Resources Revised 2 22 2016