GW1-2022-08547_Well Construction - GW1_20220503

1.Well Contractor Information:
- 1�� (! 14:.WATER ZONES-,'.
Weli`(7outraJ=N&me FROM TO DESCRIPTION
ft ft I�
�5,'Ce-A ft. ft.
NC Well Contractor Certification Number
IS:OUXER,GASING,(6r rnniti=rased wells OR lari] if-'licahle)'
Morgan Well &Pump, Inc. FROM TO' DIAMETER Zt TMCMNUS MATERIAL
Company Name
+1 ft. ft. 6 118/F in. sdt21 pvc
2W Pemit#: FROM IER C TO G OR•TIIBII�G.''eotliermalT cHIWE NESS I VllJy
MATERIAL
List all applicable well construction permits'(a.e,LUC,Cowrtx State,Ymzance,etc.)- fi• ft j in.
3.Well Use(check well use): S. .& in.
Water Supply Well:
17 SCREEN',:.. :; `_:. .`•� '•._ _.:.-:.r'r::.•. = :::. ;.' ::.:. .:::
FROM TO DIAME SLOT SIZE THICKNESS MATERIAL.
__Agricultural n_"i Municipal/Public t't ft
!Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft
Industrial/Commercial J Residential Water Supply(shared) GROUT.". " }"''• = - "
rExperimental
on FROM TO MATERIAL EMT.W CEMENT METHOD&.WOUNT
ter Supply Well: 0 ft. 20 ft. bentonfte• poured
oring Recovery ft. ft.
Well: ft ft
r Recharge Groundwater Remediation
:19:SAND/GRAVEL'PACTC if a"licafile _`.;:':.:._ :: ..','. ':•'
r Storage and Recovery Salinity Barrier FROM TO MATRRTAT. EWI LACEMENT METHOD
rTest ElStormwaterDrainage R ft
ental Technology �ISubsidence Control ft ftrmal(Closed Loop) Tracerrmal(I3eating/Cooliag Retum) -Other(explain under#21 Remarks) FROM ro D RIP.TION(color,hardness,soiUroek ly a u etc)
75 ft
4.Date Well(s)Completed: -1�`� Well ID# It ft rQJn
-
t ( ft
�S .Well Location:
- 'f �c+
l" yi A ((A� o 1'I��1MG5 ft ft 411(At, r 4 C
Facility/Owner
-Name Facility lD#(if applicable)) ft ft
I/I�(^1' 24a L&� U) ft ft
/Physical Address,City,and Zip ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,oneelllaat/long is sufficient) l 22.Certification- MAY 0­3 2022
ILV e5 W 1
6.Is(are)the well(s) Permanent or Temporary Si, tune of Certified Well cont-acto .1 m4i ,- Ear �LP,tit"f
B_v signing this form,I hereby cerfify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with 15.4 NCAC 02C.0100 or 15,4 NCAC 62C.0200 Well Construction Standards and than a
Ifthis is a repair JiH out(mown well construction information algexplain Are natm•e ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: ' % !r � SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: l0� (ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells list all depths if different(example-3(Q200'and 2@100) construction to the following.
10.Static water level below top of casing:���o (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 Infection 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,direct push,etc.)
F
ORWATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
ield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
n /_ the address(es) 'above, also submit one copy of this fowl within 30 days of
isinfection type: e-1fl( 1� Amount: ((� 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
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