GW1-2022-08584_Well Construction - GW1_20220503

rrrJl .Lj yly�AtcutlllVlV Kl+�( UHll (GW-I) I For Internal Use Only: f
L Well Contractor Information:
14:.WATER ZONES
Well Contractor Name - FROM TO I DESCRIPTION
ft-
ft ft
NC Well Contractor Certification Number
15:OII .CASING,(fo'i•rhtati-rased*&is)OR LZ R lff` NNE,,.
hle)'
Morgan Well&Pump, Inc. FROM TO DIAMETER i TEICK\FSs
Company Name +1 ft 1 ft 61181 m. sdr21 pvc
p y 16,INNn CASING OR-T[1BING:fifd6tliefiii2a closed rod :.
2.Well Construction Permit#: ` 1 �/ FROM TO. DIAMETER TEICHIdESS r MATERIAL
List all applicable well construction permits'(ie.WC,County State,Variance,etc.)- ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weil: 17-"SCREEN',.-. :'_:. .`ter ..=•_ ;..;::..;.;-: t--tz:
OM TO DrAMETER SLOT SIZE TRTCKNESS MATERIAL.
Agricultural �Municipal/Public Mom
ft in.
i Geothermal(Heatiag/Cooling Supply) Mesidential Water Supply(single) ft ft in•
I Industrial/Commercial i Residential Water Supply share _.•,•. r�,_ -.__ -:. .
PP Y d)( 18:GROUT-:-- .'
E Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonfte poured
s Monitoring EIRecovery ft ft.
Injection We"' ft ft
Aquifer Recharge KI Groundwater Remediation r. .
.19:SAND/GRAVEL'PACK(if a'livable " 7.
Aquifer Storage and Recovery Salinity Barrier .FROM TO MATERIAL '.EMPLACEMENT iTv=OD •.
Aquifer Test [35tormwaterDrainage ft ft
1I,&othermaI
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer :20..MRILLINGLOG'(attiiEi dditiorial slieets}fneces(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
C Z.c�
u I
4.Date Well(s)Completed: /^ ��'� b ft. ft Ire
LD# / ft. ft
5 WeIl Location: J / t7 Q ft scw S�Yycc
rto� L�+� LLB V ft ft
Facility/Own Name / Facility M#(if applicable) ft. ft
Pliysi Address,City,and Zip ft ft.
q� •21:REIv1ARLCS'- .,• � 1
County Parcel IdentificationNo.(PIN) 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ._,
(if well field,one lat/lon(g is sufficient) 7 22.Certifi on' p��tivt wt�T(
��`i a'l r,`rti"-:ilr"J."-SrcOr Es.^`.'1;
W n\ 6 2d2�L
6.Is(are)the well(s)IkIrmanent or OTemporary Sim ature of Certified Well Contractor Date
By signing this form,I hereby certify that the we4s)was(were)constructed in.accordance
7.Is this a repair to an existing well: QYes or kNo with15.4 NCAC 02C.0100 or 15A NCAC 02C;.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarla section or on the back ofthis 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 land surface: i 6 5.- (fL) 24a. For All Wells: Submit this form!within 30 day8 of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1000 construction to the following.
10.Static water level below top of casing: U (ft) Division of Water Resources,Information Processing Unit,
_Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: 6 (in.) 1 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method- r o Y Lp above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,'Raleigh,-NC 2769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&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: /' Jit Amount: dZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmentat Quality-Division of Water Resources Revised 2 22-2016