GW1-2022-08605_Well Construction - GW1_20220906

(����W�' •14:.PVATER ZONES
mold TO •DFSCRIPTION♦r - _
Well Co�u�ame A
_ u fL fL
/ ` ft ft
NCwell Contractor Certification Number ]3:0OZEI?L�SIIT�,(iormnlficasr3we]ls)b MMI?E'RC¢_ L'cable'v=.: .•:
Morgan Well & Pump, Inc. FROM TO' DInMETER l THIcx,YESS MATEPJA•
+1 fL 611a/ sd21 pvc
Company Name M :,.�• :. :.:. .
r�t /1 n FROM
G OB•TIIDIAD: •eotliermxl rmocmm
2.Well Construction Permit#: •�►k— �� rztoM To DTAMF�Y T>�c sS 1SAT> trN
List all applicable well construction pamits'(ie UIC,Cowdr,State Variance,etc.)- ft f
3.Well Use(check well use): ft .ft PL L, -
L
pply well: FROM TO' DIAMEmER SLOT SIZE ^TSICIMss MATERIAL.
tural 0MmnicipalJPnblic ft ft
rmal(Heating/Cooling Supply) WResidential Water Supply(single) ftaUCommercial J Residential Water Supply(shared) ,;.-.:i •M - '�,;:.:-'
GROUT•::.•..:.
fN
tion FROM TO MATFRL4L - 3wilh- II�NTMETHOD&AMOIITtT
ater Supply Well: o ft 20 fL bentonite. Poured
oring Recoveryftn.Welk ft ft•
r Recharge I GroundwaterRemediaiion •.'19:9M/GRAVEL'P9:W if a"li " ':::'r Storage and Recovery Dt SalinityBawer FROM TO MATERIAL F r12PLACM=METHOD
r Test DStomrwater Drainageftmental Technology r!Subsidence Control ftrmal(Closed Loop) DTracerFI20Ivt TO DESCRIPTION(color hardness,soillr=.ty rmal(Heating/Cooling Return) i Other(explain under#21 Remarks) It
ft.
4.Date Wells)Completed: 271 Well ID# ~j ft 3d ft-
5 Well Location: 3o fti d ft
' ft fL
Facility/O Name Facility IDn(if applicable) ft r2 '
Physical Address,City,and Zip ft ft f P e
ys'�t.� -O�-SFrl� 2I12Y2MARTIR - - '. UtSii P:.:'....i•::.`: i,
Cou
nty Parcel Identineation No.(PIN) ^ri3a:1 l t vG .l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
Cif wall field,one)at/long is sufficient) 2 ration:
•NN50 w $ J
6.Is(are)the well(s) Permanent or DTemporary zrtified we}1 Contractor D
form,I hereby rpr6fy that the weR(s)was(were)constructed in accordance
7.Is this a repair to an exisfingwel QYes or f No wuli 02C.0100 or 15A NCAC 02C,0200 FYell Construction Standards and that a
Ifthis is a repair•,fill out known weD construction information and explain the natw•e of the copy of thii record has been provided to the well Owner.
repair under 42)remarks section or an the back of thisform
23.5ite 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 TOTALNUMBER•ofweils construction details. You may also attach additional pages ifnemssary.
drilled: r {� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t�V ( ) 242- For All Wells: Submit this form within 30 days of completion of well
For multiple wells ki all depths ifdifjerent(example-3Qa(�) g.
w J
00'and 2@100D construction to the followin
10.Static ater level below top of casing: O (ft) Division of Water Resources;Information Processing Unit,
Ifwoter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells- In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: � A L` - construction to the following:
(r.e.auger,rotary,cable,dnectpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPP
PLLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) G 0 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 typ Amount 7i 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