GW1-2022-08469_Well Construction - GW1_20220906

1.VJ ontractor tion: I J
tL 14:.WATFR ZONES
well Co tnr ame FROM TO DFSCRIFTION
� ft ft. �
NC well Contractor certification Number
` IS:OVCER,G�ASIDIG,(focmniti-rased veils)O12LII�I2(ffa
Morgan Well &Pump, Inc. _ FROM T DIAMETER xmcrr, ss MATExLs�
Company Name +1 ft 6 1181 m• sd21 pvc
�1y I �II�4:Ft CASIN OR•TUBING.'•edt7ierma7•clii''a --lod' '`:"' .,_. •:;'.•.-,...-
2.Well ConstructionPf"t##:_N IT1 FROM TO DL4ML ZR TEaCB'IWS MATERIAL'
Jbt all appdcable well construction permits a UIC,County,State,rm-ance,etc-)- ft ft m'
3.Well Use(check well use):
ft. ft in
J-1
er Supply Well: .`�.. .._•=• _ „OT � •�,::=S = YTAT-.:_A
FROM TO DIAMETER~ SLOT SI28 THICKNESS IrIATERIAL.
ricultural Q� Municipal/Public ft f, in.
othemmmal(Heating/Cooling Spply) l Residential Water Supply(single) ft ft in.
ustnal/Commercial _1 Residential Water Supply(shared) ;'
hi lion FROM TO `MATERTTAL - M:2T_.r'FiwtF'4TMETEOD&AMOMU
Non-Water Supply Well: o ft- 20 ft bentonite- poured
'Monitoring DRecovery ft. ft
Injection.W-eII: ft. ft.
Aquifer Recharge J3 Cnoundwater Remediation
:.79:SAND/GRAVEL'PACK if a"licaSIe
AgniferSt.. 'and
MSalinityBamcr FROM TO MATERTAL EMPLACEMENT METHOD
Aquifer Test E]StormwaterDrainage rZ ft.
lGeothezinal
Experimental Technology ©ISubsidence Control ft ft.Geothermal(Closed Loop) Tracer ;20.7iiRII1 1HGLOG'(attaciidditionaI slieefs Ma`ecess(Heating/Coo1•ingReturn) i Other(explain under#21 Remarks) FROM To DESCRIPTION Wo,hardness,sotl/rock type,grain size,etc)
e�' ft { ft _
4.Date Well(s)Completed �\1 2_—Z an ID#} tagft A5 fL .
Sa Well Location:
S
ft. ft
Facility/Owner Name Facility 1D#(ifapplicable) ft
ad qr) Ir't 1ow�s �d Cam, . 4c, Z ft ft �,lz
/JJpp��j�y�sical�Add&c�s�s,,1 ,a
City,and Zip ft ft
`.'� - -- :-;a 1�r-' Iri• 5
"�+o `y •� :2k•R'RMARTCC — �:i - ^z" p;.>�1�:.,7y -- -
county Pa:celIdentincatinnNo.(PIN)
5b.Latitude and longitude iu degrees/minutes/seconds or decimal degrees:
(rt'well field,one lat/long is sufficient) rL�
-N<Z0 .441K t w 2 cation:
6.Is(are)the well(s) Permaneut or OTemporary Signa e f ad we}1 Contractor Date
.ring is form,1 hereby certify thof the wells)was(were)constructed in accordance
7.Is this a repair to an existing well• 0'Yes or ®No wu]i 15.4 C 02C.0100 or 15A NCAC 02C•.0200 WeH Construcdon Standards and that a
Ifthis is a repair,fill aid known well construction information and explain the nature afthe copy ofMis record has beenprovided to the well owner.
repair under 01 remarks secdon 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 I GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: �`� ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ermnple-3(200'and 2Q100)
construction to the following:
10.Static water level below top of rasing. 315 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: L� above,also submit one copy of this form within 30 days of completion of well
construction to the following.
(Le.auger,rotary,cable,directpush,etc) -
EWATER17PPLX WELLS ONLY Division ofWater Resources,Underground Injection Control Program,
• I636 Mail Service Center,Raleigh,NC 27699-1636
22 Method of test: allpressure24c.For Water Supply&Injection Wells: In addition to sending the fora to
the address(es) 'above, also submit one copy of this form within 30 days of
typ Amount: ,d 67, completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofBnvironmental Quality-Division of water Resources Revised 2 22 2016