GW1-2022-08540_Well Construction - GW1_20220503

1.Well Contractor Information:
ay T® Q I- ZONES•:'. � �'.: :. .,
Well Contractor Name FROM TO DESCRIPTION
ft ft-
-A ft j
L7 ft
NC Well Contractor Certification Numbet
15:O=-R.E4,s TG,(focmnlii=raseawens)ORLMpMifa.licable)' i...:: .`.=
Morgan Well &Pump, Inc. FROM TO' DIAMETER THIcxivEss MATERIAL
Company Name +1 ft 5 ft 6 1/B/ ' in' sdr2l pvc
�� p , FR"Il�IItER C1SII�TG OR TIIDI AArL eotbermal closed
2.Well Construction Permit#: w FROM To DIAMETER THICKNFSs MATERIAL
List all applicable well construction permits'(Le.UIC,County State,rrariance,etc.)• ft• ft. l in.
3.Well Use(check well use): ft ft, in.
W
ater Supply Well: 17:sCREEN',,:. .= `::. .`� =•,:: ?:. :: ;,,:_.::=.;--.:?•" =`•` .
FROM TO DIAMETER' SLOT SrZE TFffcFa Ss MATERIAL.
gricultural 0Municipal/Public ft fL in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ftdustn Commercial i Residential Water Supply(shared) _18:GROUT:..
Irrigation FROM I TO MATERIAL _ EMPL-4CEMENT METHOD&•AMOUNT_
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'•Monitoring DRecovery ft. ft
Injection Well: ft ft.
__I AquiferRecharge DCnoundwaterRemediation ,
,:19:SAND/GRAVEL'PACK if a'il6ble "
'Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL -EMPLACEMENT`I�THOD •.
Aquifer Test ElStormwater Drainage ft ft
I Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) [ITracer :20.DRILLING.I OG'(attacli`addition'sl slieetsjdaeces's"
Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) FROM To DESCRIPTION(cola,hardness,soiUrock s y in s ze.eel
4.Date Well(s)Completed: % L Well ID# ft a ft- �l t It r
5a.Well Location: f, owf\ �G
has /a/l�;G 1{lby,�b 0 ft. 5ft U C C4 641 1 -
Facility/Owner Name Facility ID# Le(if applicable) � ft t' f
�1lI/Il/d� adr nr:0140A Ot B0j 2 ft ft
Physical Address,
,CCittyn and Zip (� % ft
! r 1 ! 1�✓2 KJ r :71:uFnreuua - ^•a.= f
W`
b_.r
County Parcel Identification No.(PIN) MAY
o 3 ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f 1
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or [3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer•trfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ;Eli Yes or jjNo with ISANCAC 02C.0100 or 15A NCACO2C.0200 IVel1 Consruction Standards and that a
Ifthis is a repair,fill out known well construction information d explain the nature of the copy ofthis 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:__ SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 6 (ft-) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multrple wells list all depths ifdifferent(example-3 Zr 00'and 2@100) construction to the following
10.Static water level below top of casing: 80 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.well construction method O 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.) '
FOR WATER SUPPLX WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 7 Method of test• air pressure 24c.For Water Supply&Injection!Wells: In addition to sending the form to
nn Q the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: (,1OI/�+ _C_ m_ Aount: -1�� completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016