GW1-2022-10245_Well Construction - GW1_20221111

I.W ontractorInf meson:
1
0
•14:.`A.T RZONES:'.
Well Coant�f r a e. FROM TO DESCRIPTION
//AS` it ft
ft ft
NC Well Contractor Cerf>$'ication Number
15:OUZER.•CASING,(&-rmniti casedweDs)b 2L-Il 2Ctf licahle)'-1:::`.:•:: ."._
Morgan Well &Pump,Inc. =_FROM TO' DIAMMTER THICIfi s ATATMUAL
Company Name
+1 ft' 61/e/ 'm sd21 pvc
_�I I -Re ET R Ci1,SII�TG OR•TUBING. 'eotliei>aa7cio'sed�ou' .'.:`:.:�-. •; .
2.well Construction Permit#:� FROM To I DIAMETER1 THICKNESS MATER7AL-
List all applicable weUconstructionpermits'(ie WC,Counfi State,Ymiance,eta)• fL ft. I 'in.
i
3.well Use(check well use): ft ft m
water Supply well: 17__SCREEN'..:=-..: `::. .` ..:'_.:.::,:::..,:. :;::�,:'::.::- ?•-F::.. =:
FROM TO DIAMETER SLOT SIZE TETCfams MATERIAL.
Agicultural Qj Muaicipal/Public g, ft in.
Geothermal(Heating/Cooling Supply) �IResidential Water Supply(single) ft ft
I us Commercial 1 Residential Water Supply(shared) :c18:GROUT::. ' _ #*°.'•.:: -
fN
tion FROM TO MATERIAL - EMP �CEMENTM] OD&AMOUNT
ater Supply well: o ft 20 ft bentonite poured
oring Recovery ft ft
n.well:
ft ft
er Recharge K3Groundwater Remediation :.1g:SAND/GRAVEL'P9 CK ti a"livable er Storage andR=6d ery SalinityBawer FROM TO MerF.urar. FrYPLACFd14ENTtl4E1HODer Test [Stormwater Drainage ft ft.
mental Technology Subsidence Control ft ft
ermal(Closed Loop) QlTracer .DRILLING.IAG(attiLW: dditionalslieedfaeces's- .-,.rmal(Heating/Cooling Retum) -Other(explain under#21 Remarks) FROM To DESCRIPTION(wlo,hardness soillrork type rain s ze etc)
n.�—_ ) .f` jb It l
4.Date Well(s)Completed:�[..0 Well ID# it3C7 ft t..
Sa.Well Location: R ej ft k,
/\ ft.122D ft
F..mty/OwnerN a ,nnFacility1D#(ifapplicable) ft ft I( orff loon f rac3seing
��— y-�,ir anr.�tJ , � i \o� fstnlu JAG 4�, ft ft.
Physical Address, -ty,and Zip ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ywell field,one lat/long is sufficient) 2 ration
6.Is(are)the well(s) Permanent or Oi Temporary Signa e f rtified Well Contractor Date IL I
fining is form,I hereby cer&)y' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or f No wuh ISA C 02C.0100 or 1.5.4 NCAC 02C.0200 We11 Construction Standards and that a
Ifthis is a repay,fill out brown weA canshucffon utforrnation and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the bark ofthis form 23.Site diagram or additional well details:
B.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 ifnecessary.
SUBMITTAL INSTRUCTIONS
ZZO9.Total well depth below land surface: (ft-) 242-For All Wells: Submit this form;within 30 days of completion of well
For multiple wells&I all depths ifdlfferent(example-3Qa 200'and 2Qa 100) conshnlction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bor:ehoIe diameter: 6 (in.)
24b.For Infection Wells: In addition to sending the font to the address in 24a
12.Well construction method- L� above,also submit one copy of this form within 30 days of completion of well
(i.e.auge,rotary,cable,directpush,etc construction to the following:
) •�
Division of Water Resources,Underground Injection Control Program,
L13b.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
Yield(gpm) Method of test: air pressure 24c.For Water SunpIy&Injection Wells:; In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection typ Amount: completion of well construction to the county health department of the county
where constructed_ r
f .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016