GW1-2022-09700_Well Construction - GW1_20220503

Diu lit.t Ito lN.CCZ',Uy (UW-1) For Internal Use Only.
I.Well Contractor Information: p
bg r e-,-w CIQ�►,sc .14:.WATER ZONES
Well Contractor Name FROAJ. TO DESCRIPTION
ft-
ft. ft
NC Well Contractor Certification Numbet
15:OUXURRASING,(fncmniti=raseaFvelLs)OA-IMUR(ifh
Morgan Well&Pump, Inc. FROM T DIAMETER i THICF'1ES5 'li MATERIAL
Company Name
+1 ft ft 61181 in' sd,21 pvc
'.�:.,":..:• �•.:;..,.•,..: .
//�^G� 16:Il�IIQER CASING Olt•TQBIIVG. -eotlier'mal•clo'sed-rod
2.Well Construction Permd3�#: ( 90? FROM TO. DIAMETER 1 7MCENESS MATERIAL
List all applicable well constructionpermits•(Le.UIC,County,State,Variance,etc)- ft ft. in.
3.Well Use(check well use): ft .ft in
Water Supply Well: 17_-SCREEN :`:,. .'�<'._`_:::. ?:. :.•. -;>.. ..':':.;•:.,.--,::.:. .:: .' .-:
FROM TO DIAMETER SLOT SIZE THMICMS I MATERIAL.
i Agricultural Mj Muaicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I Industrial/Commercial 0Residential Water Supply(shared) GROIIT•::.
Irr ation FROM TO ,MATERIAL EMPLACEMNT E METHOD.&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
'•Monitoring QRecovery ft ft
Injection Well-
ft ft
Aquifer Recharge KI Groundwater Remediation r.
'Aquifer•Storage and Recovery '©salinity Barrier :'FROM I-TO ND/GRAVEL'PACK TEtiR-IALIe •.•.;. '.FIMPLe10E[vD;NT TROD-,••',..,
Aquifer Test D Stormwater Drainage ft ft
i Experimental Technology ©lj Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.IT) G-LOG(attach additivaiiI S16ets•if fiecess �. ,
I Geothermal(Fieating/Cooling Return) Other(explain under#21 Remarks) FROM TO D CRIPTION color,hardness,saillrock a in sae,etc)
ft ft ,- ,✓
4.Date Well(s)Completed~ -qz� Well ID# / ft
WeI1 Location: u
I/G ���SV/� S R ft (yt),S ��
acility/iOlwnerName ,{� Facility ID#(ifapplicable) ft. (� (�C /4i,• �
70 It) ��� l 1 � �Zdc kA.<-U- Loft -7 b ft- 7n11
Pliyssiicaall Address,City,and Zip �— ft ft
S—.
County Parcel IdentificationNo.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY 3
(ifwell field,one lat/long is sufficient) 22.Certification'
3
N a. V7SgS
6.Is(are)the wells e' rmanent or [3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cvl*that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 4&o with]5ANCAC 02C.0100 or 15.4 NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction ififormation and explain the natm•e of the copy ofthis record has been provided to the well owner.
repair under#11 remarks section or on the bark ofthisform. 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 I 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:_ 27b (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 200'and 2 00q construction 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
r L� above also
to the following:
also submit one copy of this form within 30 days of completion of well
12.Well construction method: cQ constru
(i.e.auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 5V - Method of test: air pressure 24c.For Water Suumly&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: rein&I&ii- Amount: to 6ti completion of well construction to the county health department of the county
where constructed
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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