GW1-2022-10225_Well Construction - GW1_20221111

L W. ontractor I ation:
14:.W9-TXR ZONES
Well Con for am FROM TO I DESCRIPTION
& ft.
� r ft. ft
Ni-Will Contractor Cer4cation Number
15:OUXEI�-G�ASING:(fac mnitivased webs 0_L pit(if a'licahle)'-,
Morgan Well&Pump;Inc. = FROM I TO' D»TER i THIMNESS MdTRRTAr.
Company Name +1 ft ft 61/8/ f in' sdf21 pvc
q^ 16.-DeUR CASING OR•TUBING: g edttier'ma1•aidse&Ioo ?.'.:.,
2.Well Construction Permit#: �1 "1L��b FROM TO DT AM-I R THICKNESS MATERIAL'
List all applicable weNconstructfonpermits'(te C Cowtty,Stale,Ymiance,etc)• ft. ft. 1 in.
c
3.Well Use(check well use):
ft ft in.
1VSCREEN',.'­'. •.a•. :,i'- '. t,.:
AVIaler Supply Well: i ROM TO D1AME[Ekt SLOT SIZE YTEiTCFQQFSS MATERIAL.
Agricultural DMunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) 'Residential WaterSupply(singleftIna Commercial Residential Water Supply(shared) .Y8:GROUT:: - - '` -
fN
on FROM TO MATERAL EMp C'I w� 4TMETHOD&AMOUNT
ater Supply Wen: o ft 20 ft. bentonite• poured
oring Recovery ft ft.
n.Well: ft ft
er Recharge Groundwater Remediation
'19:SAND/GRAYEL'PA,CK if applicable)
.•::.. ":;:':.:._ .:'. ..`.'=,
r Storage and Recovvery DSalinityBarrier FROMTO MATERIAL ENLACEMENT iNEMOD
r TestOStornwater Drainage fLmental Technology Subsidence Control ftftrmal(Closed Loop) OTracer :20.DR1=G.LOG'(ittacBjidditiunaIseetsrmal eatino Coolie Return Other FROM To(Ii e/ g ) (explain under#21 Remarks) d ft ft
c,l
4.Date Well(s)Completed:Vb 22JWell]D# leg: It
ft r
52.Well Location:
O ft ft
R ft
Facility/Owner Name Facility ID#(if applicable)
NA
ft ft
Physical Address,City,and Zip ft t f
W L' Vy7--2-0 -
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
'(n�well field
,
one
lat/long is sufficient) 2 ration: n''
2-- - 16
6.Is(are)the wells) Permanent or OTenporary Sigma f rtified Well Contractor Date
B gaLog it form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or.®No wuh ISA C 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standm•ds and that a
Iffi s•is a repair fill out known well construction information and explain 1he nature of the copy ofthii 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 weR details:
8.For Geoprob'e/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 NUNMER bf wells construction details. You may also attach additional pages ifnecessary.
drilled: it SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:AM (ft) 242. For All Wells: Submit this foam within 30 days of completion of well
For multiple wells&t all depths ifdifferent(exmnple-3Q200'and 2@100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources;information Processing Unit,
If water level is above casino 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
12.Well construction method: L{ above, also submit one copy of this£om1 within 30 days of completion of well
(Le-auger,rotary,cable,daectpush,etc.) construction to the following: �•
Division of Water Resources,Underground Injection ControI Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 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[yp Amount: DOZ 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 i Revised 2-22 2016