GW1-2022-08577_Well Construction - GW1_20220503

--- -.• r, �.��.y xvi.ItJc l VAiU (ts VY-A) I kor Internal Use Unly: f
1.Well C tractor Information: C I!
C(c�UJe_, 14:.WATER ZONES,,'.
GWell Contractoy Name FROM TO I DESCRIPTION ft ft .
ft. ft I
NC Well Contractor Certification Number
OU2'ER:G�ASNo,fnc tuniti=t�edweIls OR LZHE12 if a'likable}'.;;=::?:'.:�'
Morgan Well&Pump, Inc. FROM TO I' DIAMETER TEICENESS MATEPJAL
Company Name +1 ft ft 61/8l iu. sd,21 pvc
S 6��l/� 16"hVNER ChSIIQG OR TIIBII�G: 'eotfiei?mal closed lod`L':. :; -
2.Well Construction Permit#: FROM I TO. DIAMETER ; THICKNESS MATERIAL
List all applicable well construction permits•(ce.UIC,Count,State,Variance,etc.)- ft ft• in.
3.Well Use(check well use): ft ft. in.
Water Supply Well:
i A _icultural FROM TO DIAMETER SLOT SIZE �THTCKNESS MATERIAL.
bn DMunicipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft
Industrial/Commercial DResidential Water Supply(shared) 8:GRODT::• :; '' "
Ini ation FROM TO MATERLAI, -: EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
'.Monitoring URecovery ft ft
Injection Well:
Aquifer Recharge EI ft ft
Groundwater Remediation r.
:.19:SAND/GRAVEL•PACK ti a"likable P" _ _ ..•
' ...
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test LJI Stormwater Drainage ft R
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.EOG'(attach'sddition'slslieefs�faeces's" !.. -
Geothermal(Heating/Cooling Return' Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, in s ze etc.)
C).ft. ,D ft t�
4.Date Well(s)Completed: 7 Well ID# / ft 0 it
5a.Well Location: J ft M.r• n p
CAr / ;,2c4C,1�— / J ft ft
Facility/OwlieerName Facility
yID`##(ifapplicable) ,A► a ft. J ft
_,�1�/ I •��l�I t�9�.+ 1 - •`/ li'lrn lC /U V_- ft ft
mysical s,City,and Zip ., ft ft
County Parcel IdentificationNo.(PII,J)
MAY 0
5b.Latitude and longitude in dee ees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/long is sufficient) 22.Certification' ' "
3� 6/S9'7 N PC)- ley9Sq w w' M,�4-1
6.Is(are)the well(sPermanent or EITemporary Signature of Certified Well Contractor Date
"TTTT By signing this form,I Hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes 0 1 NO with ISA NCAC 02C.0100 or ISA NCAC 02Ct 0200 Well Construction Mandm•ds and that a
Ifihis is a repau,fig out known well construction hifc motion an explain the nature of the copy ofthii 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 1 GW-1 is needed. Indicate TOTAL NUMBERof wells construction details. You may also attach additional pages if necessary.
drilled: ' - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �U (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferew(enunple-3 a200'mud 2@100)
v construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino 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- r��Y Lj above,also submit one copy of this forum within 30 days of completion of well
construction to the following:
(i.e.auger,rota cable,direct push,etc.)ry,
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 Sunnly&Iniection 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: ir410 r Amount: /D U Z, 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