GW1-2022-08595_Well Construction - GW1_20220906

Vill •14:.Wb-TER ZONES
Well Co for are FROM TO DESCRIPTION`c
ft ft
A ft fL
NC Well Contractor Certification Nrmbet
-IS:O'OZ'ERCASING,fni•mnitf irsea*iils OR LII R rt"-'
Morgan Well&Pump, Inc. : FROM TO' DIAMMR cr ss MATERIAL.
Company Name +1 ft ft 6 1181 sd,21 pvc
31�5�0 16:�R GOE•TOBING: e6theimalrlo'sea,
2.Well Construction Permitw: �V( FROM TO DIAM TZ 4 THICKHM METT �-
List all applicable weg construadon permits'(L e.UIG Cowx%State,Parlance,etc)• ft ft
ft ft hL
3.Well Use(check well nse):
Water Supply Well: 12"SCRffi7'. .`;r'.:•: _ ;:;:.,.•:•�� .
FROM TO DIAMETER SLOT SIZE I:THICKNESS TvLkTERLL.
!Agricultural E3MunicipabTublic It
ft tr-
(Geothermal(Heattng/Cooling Supply) *Residential Water Supply(single) ft fL
I Tndustn Commercial J Residential Water Supply(shared) ZGROUMT -': ; :. --:: ::'on MATERJAL � BMPLACEMENTNon-Water Supply Well: ft bmion'tte• pow'Monitoring Recovery ftfL
Aquifer Recharge I]GroundwaterRemediation
PAquifer Storage and Recovery !Dt SalinityBawer MATFRTAT. ELMPI.ACEKENT METHODAquifer Test E3&ormwater Drainage f
J Experimental Technologyi�-+Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRTLGII�'GLOG'(attacliaddiiionaIslieefslfaec '7'f_ ::_> .'€ .':' r:':,.
Geothermal(Heating/CooIingRetum) J Other(explain under#21 Remarks) FROM TO DESCRIPTIONJ(collor,tLvaness soiurnoktype size etc)
rj AA Ah 0 .ft to ft %A
4.Date Well(s)Completed: ! FZ M Well M# 0• ft. .�-5 ft.
Well Location: 5 ft 35 ft
6A _J J
Famlity/Owner Name Facility 1D# applicable) ft
(if ft.
2 fL ft. SE P 0 0 2022
Physical Address,
p ft ft n.
County Pa:celIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sufi5cient) 2 tion'
3$.522b N 10 W ? Z6 22
6.Is(are)the well(s) Permanent or DTemporary Sign. f rtified Well Contractor Date
Amino is farm,1 he.? certify that the weR(s)was(were)constructed in accordance
7.Is this a repair to an existing weIk M Yes or *No wuh 15.4 C 02C.0100 or ISA NCAC 02C•.0200 YYeff ConSftCdDn Standards and that a
Ifthis is a repair•,fiR out known well construction information and eiplain the nature of the copy of this record has been provided to the well owner.
repair under#11 remark section or on the bade of Iltis 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 NUNMER'of wells construction details. You may also attach,'additional pages if necessary.
drilled: SDBMCTTAL INSTRUCTIONS
9.Total well depth below land surface: 0 2'0 (ft) 24a.For All Wells Submit this form within 30 day5 of completion of well
For multiple wells list all depths##*different(eranple-3@200'and 2Qa 100D construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
I1.BorehoIe diameter: 6 (in.) ( 24b.For Injection Wells: In addition to sending the foim to the address in 24a
12.Well construction method-. 0�+'L} - above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,d¢ectpusl;eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY MILS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test: air pressure 24c.For Water SuDDly&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 typ Amount . completion of well construction to the county health departnent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
i