GW1-2022-08446_Well Construction - GW1_20220906

1.W ontractor Inf -oration:
IV 14:.WATER ZONES
Well Co [or ame FROM TO DESCRIPTION
ft ft
� r fit fit
NC Well Contractor Certification Number
15:OUTER:CASIl�Tts.(foc multi=6asea webs)OR Mi E12(rfapx _
Morgan Well&Pump, Inc. FROM TO' DIAA4:ETER Tarcm-E3S+1 ft 61181 sd,21 Company Name 2.Well Construction Permit#: .? THICENMS MATERIAL
List all applicable well construction permits'rL e.LUC,Cow4v,Stale,Ymiancc,etc)- ft• ft. m
3.Well Use(check well use):
ft. ft in
Water Supply Well:
FROM TO DTAMET'E`R SLOT SIZE TATCKNMS TYIATERTAL.
Agricultural 6i Municipal/Public ft ft in.
i Geothermal(Heatmg/Cooling Supply) DResidential Water Supply(single) ft ft �•
I�Tindust-lrTCommercial _Residential Water Supply(shared) 18;GROUT-.'..' -
I Iui ation FROM TO MAATERLaL Eh7PL_4CEMENTMETHOD&AMOWiT
Non-Water Supply Well: o fir 20 ft bentonite- poured
Monitoring Recovery ft ft
TA
n.Well:
fit ft
r Recharge MI Groundwater Remediaiion 19.��/GRAVEL'P9 CK ti a"linable " . ..:,-
rStorageandRecovery nSalinityBamer FROM TO MATEMAL EMPLACEMENTiv=OD
r Test QlSt). ater Drainage mental Technology �1Subsidence Control fit fit
rmal(Closed Loop) EITracerEft.
mral(Heating/Cooling Return) Other(explain under#21 Remal3cs) To DESCRIPTION(colorhardnesssoi. Q ft Ao ft
4.Date Well(s)Completed:O�Well ID# ag ft-
ft.
Sa.Well
/Location:
e_ e
ft . `-c eta..�. ,�i_.5 V ...,......°t
Facility/Owner Name Facility ID#(if applicable) ft ft
l 3�o LD k5jaC IRA MLT-" k N(,zg ft ft.
Physical Address,City,and Zip ft ft
County Parcel Identification No.(PIIq
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one- Qlat/long is sufficient)
-i),S z4 -N Od.35'AZ W acanon:
6.Is(are)the weR(s)*Permanent or OTemporary Sign a e f rtified Well Contractor D
B fining is form,I hereby cerirfy that the well(s)was(were)constucted in acrordance
7.Is this a repair to an existing well: QYes or J@No watt 15A N C 02C_0100 or 154 NCAC 02C:0200 Fell Conshvction Siandm•ds and that a
1jt]us is a repair•,fill out known well construction idformation and explain the nature of the copy ojthis record has been provided to the well owner.
repair under#21 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:__ w on SUBMCTTAL INSTRUCTIONS
9.Total well depth below Iand surface: L.Lx;l (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulaple wells Est a!1 depths ifdt�erent(example-3 20/0''mrd 2@109) construction to the following.
10.5tatic water level below top of casing: L y (ft) Division of Water Resources,Information Processing Unit
If
water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells- In addition to sending the foam to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A L1 construction to the following:
(le.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYW ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
n V
13a.Yield(gpm) LY Method of test: air pressure 24c.For Water SupDIy&Injection 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 typ Amount:Ttl7i completion of well construction to the county health department of the county
where contracted_
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of WaterResources Revised2-22-2016