GW1-2022-08492_Well Construction - GW1_20220503

-uu vl\UAA\ULA1V1�(jCC( (fjif� ((Th/-j) I For Internal Use Only:
I.Well Contractor Information:
- G� U �
I W1_TER ZONES-,'. ,
Well Contractor Name FROM TO I DESCRIPTION
ft ft
ft ft !
NC Well Contractor Certification Number
� 'I5:OU7'EI2,EASING,(formniti=caseiiwells b_TTNF.R(ifa'Ticable)'j:�":'.:,::'•.
Morgan Well& Pump, Inc. FROM TO' DIAMETER THICS�FSs MATxnrnx.
Company Name +1 fL 6 ft 6 1/81 In' sd21 pvc
3-7 ,6 iti."]NNRZ2Cr1SII�T OR•TQB]1�G. 'eotlierma7cIo'sed lod' :. "=';'
2.Well Construction Permit#: 8 FROM TO. DIAMETER 1 THIL-famS MATER AL
List all applicable well construction permits'rLe.UIC,Cowdy,State,Variance,etc)- ft ft In•
3.Well Use(check well use): ft M in.
VAgdcultural
upply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
DMunicipal/Public ft ft in.
rmal(Heating/Cooling Supply) residential Water Supply(single) g ft in.
ial/Commercial E3Residential Water Supply(shared)
::IS:GROUT-:;•".:; _ :;-__;r 1.:. .,;:,:'.:. •..•„ .:._. .:.•,:_.,...: ..
E Irri ation FROM TO MATERIAL EMPLACENMT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 bentonite poured
Monitoring Recovery ft ft
Injection Well:
M ft
_ Aquifer Recharge 1J Groundwater Remediation
19:SgND/GRAVEL'PACK tf a"livable !.. :`;:': :: ..'i,`•'.'• °.:[:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) 13Tracer :20.tiI2IL LaIG�OG'(attai ti addifiousl s7ieets�f aecess"7'�' :'%
I Geothermal(Heating/CooIing Return) i Other(explain under#21 Remarks) FROM To DESCRIPTION(rotor,hnrdnea soil/rock type in s ze etc)
ft.
ft.
Vie
4.Date Well(s)Completed:?-7- ' Well ID# v ft. LID ft. 14ft",
Sa.Well Lo tion: l\ O ft ft $ ""t 1-
r%Q� ©cuI
Facility/Owner Name �f Facility lD#(if applicable) ft ft
Z Z V6 ��+rycl 1"� �C��S b � ft ft
Pli al Address,City,and Zip ft ft
County Parcel IdentificationNo.(PIN)
..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) r�A,r
�� 22.Certification: MIR NUM
'N Sa_ 39V116 W 1AC,
6.Is(are)the well(s)J§Lermaneut or O'Temporary Sijnature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ONO with ISA NCAC 02C.0100 or 15A NCAC 02C:10200 FPell Construction Standards and that a
Ifthis is a repair fr1Z out known well construction information and explain the natw•e ofthe copy ofthis record has been provided to the well owner.
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 i GW-1 is needed. Indicate TOTAL NUNMER'of wells construction details. You may also attach additional pages if necessary.
drilled: • 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: zoo (ft) 24a, For All Wells: Submit this form'within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 00'a7(0
000 constriction 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
IL Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to'sending the form to the address in 24a
12.Well construction method: r L� above,also submit one copy of this form`within 30 days of completion of well
(ie.auger,rotary,cable,duectpuslr,etc.) J
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water Sunuly&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 type: J f'tA-4 - Amount: "_ L- completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016