GW1-2022-10228_Well Construction - GW1_20221111

1,W ontractor 1nf matron:
—V �ftt_g :J�cuf
14:.WATER ZONES
FROM TO DESCRIPTION
Well Co or time R ft
NC Well Contractor Certiocation Number 15:OU�ER.CASING,(ior mnlfi=dasediwe]Ls)OR
Morgan Well&Pump;Inc. FRoM TO' DIAMETER TRIclaliEss MATERIAL
+1 ft ft 61181 sdr21 pvc
Company Name
� .,�,�-1 16.`�.R CAS'Il�TG OR•TOBING'-entlier'tuslclo'sed-moo'
2.Well Construction Permit#: otk •�j,�—ty+ FROM TO DIAMETER TJ�CFQIFSs .:: MAT'ERIAL'
List all applicable well constmctfonpermits'(t e.UIC,Cowdv,S=e,Ymiance,etc-)' ff ft in.
S. ft in.
3.Well Use(check well use):
-SCREEN',-*,.-..:,:fl _ .:r,. . . . ..
VAgdcuitural
ply Well: FROM TO DLIMETER SLOT SIZE yTTirclamS MATERIAL.
EDMunicipal/Public ft ft in.
al(Heating(Cooling Supply) Residential Water Supply(single) ft " fcCommercial 1 Residential Water Supply(shared)
IIIi atiOn FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft ft.
snjection.Well: ft ft
Y!Aquifer Recharge Q Groundwater Remediation
19:SgND/trRAVEL'P9 CK tf 2-PP"Iicafire
Aquifer Storage and Rec&ery OSalinity Bawer FROM TO MATERIAL E T METHOD
Aquifer Test DStormwater Drainage ft
i Experimental Technology OSubsidence Control ft. IrIEOr�'�•►3 f;ram
r
Geothermal(Closed Loop) OTracer :ZD.DI2ILLING.DOG'(itticY ddidail sheetsifrecess '-:.
I TO DESCRIPTION(color,hardness,soil/rock type,grain size etc)
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) d It 2 d ft
ft
4.Date Well(s)Completed: b 2' Well ID# � ft
ft ft
S�a Well Location:: /',
Facility/Owner Name Facility ID#(ifapplicable) S ft G
S�SZ W�Sara. L�l Irc Lk Care,, itt u(.Z4�� ft
ft ft
A'calAddress,City,and Zip
ta3—�53`"�� •21.12>:'MbRua'-- _ - - - -= --- - - '- -
1545
county Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tfwell field one]aUlong is sufficient) Q 2 cation:
1S . 3d N Do.�53 W A 2Z
6.Is(are)the well(s)*Permanm or Temporary
Sign f ed Well Contractor Date
B o ung is form,I hereby certify that the well(s)was(wet'e)constructed in accordance
7.Is this a repair to an existing well: []Yes or f No wuh 15A C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standen ds and that a
If this is a repair,fLl out known we;construction ififormatfon and explain the nature of the copy ofthii record has been provided to the,well owner.
repair under#21 remarks section or on the back of thisforuL 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
constmctioA only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: op (ft-) 24a. For All Wells: Submit this film within 30 days of completion of well
For multiple wells list all depths ifoUf$erent(example-3Q200'and 2(100) construction to the following.
i
10.Static water level below top of casing: -a (it) 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 (ia.) 24b.For Iniection Wells: In addition to sending the fbrm to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r—UI LAL� construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) \C/ Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
���(j the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: UOZ completion of well construction to the county health department of the county
where constructed.
Revised 2-22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources