GW1-2022-08607_Well Construction - GW1_20220503

iI.Well Con�ptr\�actor Information: '
"T C I Q�Pi 14:.WATER ZONES - :•: :.: ,
Well Contractor Name FROM TO I DESCRIPTION
ft V6 ft `
ft ft
NC Well Contractor Certification Numbet
15:OUTER:CASING,(iac multi=cased webs OR ID=
Morgan Well&Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name n, +1 ft ft 61/a/ in. sd21 pvc
2ti 16.`INNER C- G OR•TUBING: i eotliermal'cldsed Lori'
2,Well Construction Permit#: 111 FROM I TO, I DLAMETER I THICKNESS MATERIAL
List all applicable well construction permi&(i a MC,Cotatty,State Variance,etc.)- ft ft m.
3.Well Use(check well use): ft it. in.
U112duStrial/Commercial
Supply Well: 17.
FROM TO - -•.DIAMETER'.-SLOT SIZE THTCKNFSS MATFRTAL
ultural CiMunicipa/Public ft ft in.
ermal(Iieating/Coo]ing Supply) Residential Water Supply(single) ft ft in.
JResidential Water Supply(shared)
ation ::18:GROUT•:..-- : ': 'z:=::;:e-=.::: :..-- ':`: ti•:: '.:_:.::;.
FROM TO MATERIAL EMPLACEMENT METHOD&4MOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'Monitoring DRecovery ft. ft.
Injection WeII:
ft ft
_Aquifer Recharge QGroundwaterRemediation
Aquifer Storage and Recovery Salmi Bawer �:SAND/GRAVEL PACK tia"linable
ty FROM TO MATERL41 -EMPLACEMENT METHOD •.
_`Aquifer Test 0stormwater Drainage ft ft.
I Experimental Technology oSubsidence Control ft ft
i Geothermal(Closed Loop) Tracer :20.DRIIS.IIVGS;OG'attiicli�addition'sl slieetsjffieces's. `:;' ':=s --
1 Geothermal(Heating/Cooling Return) r-ij Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,gmin size,etc.)`
4.Date Well(s)Completed: V� Well ID# p. ft N
Sa. lJ
Well Location- A // ft 1,b ft � fW;
Te,� A 7 ct / ft ft
Fac ' /Owner Name Facility ID4(ifapplicable) ft. ft
Physical Address,City,and Zip "�) 7 \/ ft ft
C> �/ 06 U,5�61 —
County Parcel IdentificationNo.(PIN) MAY 0
/�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 022
(rf well field,one'at/long is sufficient) 22.Certification:
`� �1�75 N 8'�.8 l6 w _..
6.Is(are)the well(s) 'Permanent or ©j(Temporary Signaffire of Certified Well Contractor Date
By signing this form,I hereby certify that the r ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or&No with 15A NCAC 02C.0100 or ISA NCAC 02C 0200 Well Construction Standen dr and that a
Ifthis is a repair fiD out known well construction information and explain the natut•e of the copy ofthis record has been provided to the well owner.
repair under#21 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: Z Z,�+ .(ft) Ma. For All Wells: Submit this form within 30 days of completion of well
For muLiple we!!s list all depths(different(example-3@,200'and 2Q100) construction to the following
10.Static water level below top of casing: G/U (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: Y LI above, also submit one copy of this form withal 30 days of completion of well
(Lc- ry,auger,rota cable,directpusll,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) I 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: I flf"J14,1 Amount: !Ck completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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