GW1-2022-09261_Well Construction - GW1_20221003

VYL�LL� VIVJ11iU1 11V1Vk(ECURD (UW-1) For Internal Use Only I
1.Well Contractor Information:
_ C��n�G I��` V� •14:. ATERZONES;'. :•: � ':.�', . - -
Well dontracAr Name FROM TO DESCRIPTION .
C) A ft. fL
fL ft
NC Well Contractor Certification Number
bl
'15:0'OTERG�ASIN�,(focmnifi_rased`vells)O$I�'F.Z2 if ae'.:�::'.`.::'•.'._
Morgan Well &Pump, Inc. FROM TO. I DL4TvXMR I TFIICX-IWS I MATERIAL
Company Name +1 ff ft 61/8/ ` sd21 pvc
r ' 16 hQI�R G 09-TOB]249 "eoth-r'ma1'd6•sedaoo" ?.':.:"
2.well Construction Permit#:_ I /� FROM TO I DZ9N'IETER I.THICHNESS MATERIAL
List all applicable we17 construction permits'(e WC,Couruv,State,Variance,etc-), ft ft in.
3.Well Use(check well use): fi' ft in.
Water Supply Well: 1 Z SCREEN'.:.:. : - - .:::?.:.• .;,.:::.: .. t. ::.:.
FROM TO DLUTETZR SLOT SIZE TffiCKNESS MATERIAL.
Agricultural QMunicipaUPublic ft. ft in.
Geothermal(Heating/Coolizig Supply) aResidential Water Supply(single) ft. ft in•
7 Justri Commercial J Residential Water Supply(shared)
Isi anon FROM TO MATERIAL ma1.kCEMENTMETFIOD&AMOIINT
Non-Water Supply Well: o fL 20 ft- bentonite poured
Monitoring DRecovery ft ft
Injection Well:
J AquiferRecharge DGroundwaterRemediation ft ft.
.-9:SAM/GRAYEL'PA d a`•Cg 'Beal e '
Aquifer Storage and Recovery DSalinityBarrier FROM TO • MATERIAL EiYPLACFd1�NT METHOD
Aquifer Test DStormwater Drainage ft ft
t Experimental Technology OSubsidence Control fL ft
i Geothermal(Closed Loop) OTracer :2e.DRILLING.L'OG'(httiLli'sdditlaiI sheets if aeces's"7 '•
Geothermal(Heating/Cooling Return) r_J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saflftck ty a in size,eta)
4.Date Well(s)Completed: 03 3 l 7-vwell ID# 'L fL
5 fL C �ZaG Sa Well Location: ft '
fL 60 f c
Facility/Owner N e Facility ID#(if applicable) fL ft
Physical Address,City,and Zip ft ft [
'21: •i.
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one la/t/long is sufficient) 22.Certification' C� /
6.Is(are)the well(s)MPerrnanent or DlTemporary Si tore of Certified VAR,6ontractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or WO with 15A NCAC 02C.0100 or 15A NCAC 02C:0100 Well Construction Standards and that a
If this is a repair fill out known well construct on information and esplain the natw-e ofthe copy ofrhis record has been provided to the well owner.
repair under#21 remarks section or on the barkofthisform. 23.Site diagram or additional well details:
S.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: zoo (R•) 24a For All Wells: Submit this fern within 30 day5 of completion of well
For multiple wells list all depths ifdi,�erent(example- )700'w&2 100D construction to the following.
10.Static water level below top of casing: / V (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to'sending the form to the address in 24a
L[ above,also submit one copy of this Rum within 30 days of completion of well
12.Well construction method:
(Le.auger,rotary,cable,direct push,etc.) -� construction to the following:
L13b.Disinfection
WATER SUPPLY WELLS,rJNLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) Method of test: air pressure 24c.For Water Sunuiv&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
type: G �i- Amount: 1 O completion of well construction to the county health department of the county
where consrrutted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016