GW1-2022-08623_Well Construction - GW1_20220503 (2)

L Well Contractor Information:
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d A4 -S;�, •14:.WATER ZONES
WeilleontracillbrName FROM TO I DESCRIPTION
ft ft
ft ft
qtS - E NC Well Contractor Certification Number
'15;OUTER,eASII�r�,(foi multi=cased'wells)ORL7I�E)t ifa"licahle's:::`.,::
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICKNESS MATERIAL
Company Name +1 ft. ft 6 1k6/ in' I d,21 pvc
� 16.'ll�IIQERCA,9NGOR•TOB7NG."-eotfiei=msl�do'sed-lod' r "`'•�' <:•:�
2.Well Contraction Permit#: �!/ , FROM TO DIAMETER TEICKLQESS MATERIAL
List all applicable well construction p its(t.e.WC,Cowity State,Variance,etc)• ft.
t ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 12 SCREEN', _•.:: ?::. i =• (..: G-.?.'�::.:. .:='•` .
FROM TO DIAMETER SLAT SIZE -TAICKNESS MATERIAL.
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Agriculttn-al DMunicipal/Public ft, ft in
Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single)
ft ft in:
ustri Commercial Residential Water Supply(shared) ,I8:GROUT-."..
b.Irrigation FROM TO I,MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite: poured
Monitoring [3Recovery 8. ft.
Injection Well: ft ft
_J Aquifer Recharge Groundwater Remediation 19;S A N D/GR AA.VFS'PA CT{if a'livable
,. .,
Aquifer Storage and Recovery DSalinity Barrier FRoM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OITracer :20.tiRILLING.LOG'(attadi`addifion'aI slieetsif fiecessa -j'r t i:.t :'r
Geothermal(Heating/Cooling Retam) J Other(explain under#21 Remarks) FROM TO fL DESCRIPTION(color,hardness,soillrock type, size,etc.)
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4.Date Well(s)Completed: Well ID# 10 ft LA 0 ft. 1
ft5a.Well Location:: Qofftt �oV (� I-j"
Og m ft Q '
v
AcilrtyOwnerName t
l Facility ID#(if applicable) ft. f
9_2�46' Clj on.'A"N, " ft ft.
Physical Address,City,and Zip
ft ft
'Rli.MARTI.C".' _ _ •ire•.
County Parcel Identification No.(PIN) MAY
—
5b.Latitude and longitude in dee ees/minutes/seconds or decimal degrees: A I
(ifwell field,one lattlong is sufficient) J l(� 22.Certifiration-
Ng)
pm
6.Is(are)the well(s) Permanent or E3Temporary S' of ed Well Contractor Date
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: Q Yes orI No with 15A NCrlC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standmds and that a
Ifdis is a repair flt out known well construction information oneesplain the nature 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 NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ ISUBMPPTAL INSTRUCTIONS
9.Total well depth below land surface: 2— ) (ft) 24a For All Wells: Submit this form within 30 day§ of completion of well
For multiple wells list all depths if different(example-3 et 00'and 2Q100) constmction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole 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 iform within 30 days of completion.of well
12.Well construction method: roY LI
(Le.auger,rotary,cable,dtreetpush,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also sublriine copy of this form within 30 days of
13b.Disinfection type: C�Y ' Amount: completion of well construction to the county health department of the county
where construbted.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016
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