GW1-2022-10721_Well Construction - GW1_20221208

1.WkII.Cantractor lnf meson:
•14:.D79-TER ZONES
Well Con are mom TO DESCRIPTION
ft. ft4
t
NC Well Contractor Certification Number
15:OUTER GASTNG.(for xLdfi-caged evens)OR 121ER tfa. cahle li ,y
Morgan Well&Pump;Inc. FROM TO' I DIAMETER TBICI=S I MATERIAL
Company Name +1 ft- Z O ft 61/a/ m sd,21 pvc
10DNNER G 01Y•TIIB7NG: 'eotfiermal closed too`L; " . : j' :
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well construction permits'(te UIC Comity,State,Ymiance,etc)- ft- ft. In.
3.Well Use(check well use):
ft. .t. in.
Water Supply WeIl:
FROM TO DIAMETER SLOT SiZS THICKNESS MATEfUAL.
Agricultural DMunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) �•
l Commercial Residential Water Supply(shared) 18:GROUT:;• _ `-: - -
•.Im ation I FROM I TO l MATERIAL EMP "CEMENT METHOl3&AMOUNT
Non-Water Supply Well: H&&LND/G
ft, 20 ft. bentonite• poured
Monitoring DRecovery ft
Snjection.W-eII: ft.
Aquifer Recharge Mt Groundwater Remediation
RAVEL•PACK tf-'blicabre Aquifer Storage and Rec6'ety MSalinity Barer TO MATERIAT MaLACEMENT METHOD
Aquifer Test DStormwater Drainage ft.,
i Experimental Technology OSubsidence Control ftGeothermal(Closed Loop) OTracerGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,saiUrock ly grain size,etc)
r 11 'Q
4.Date Well(s)Completed: L.122, Well ID# l b t- 2,0 ft.
Sa.Well.Location: it W ft
ft ft.
Facility/Owner Name Facility lD#(ifapplicable) ft ft �' a va
g25a s1-. tea. tq ft ft.
Physical Address,City,and Zip ft ft _
-
County Parcel Identification No.(PIN) r•1`„'%1;;`�i:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rf'well field,one lat/long is sufficient) 2 er ration-
35.t�?�o5 N cswO.` `�Tf W
6.Is(are)the well(s) Perranent or r3Temporary Signa yfrl.6ed Well Contractorpvnfrm,I hies ebv certify chat the we11(s)was(were) onstructed in accordance
7.Is this a repair to an existing well: ©Yes or fNo mm I5A 02C.0100 or 15A NCAC 02C.0200 Well Constvction Standards and that a
If this is a repair,fill out!mown well construction information and ex
repair under#21 remarks section or on the bark of this form plain the nature of the copy ofthis record has been provided to the well owner.
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 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: l vv. (ff) 24a. For All Wells: Submit this form within 30 days of completion of well
For multple wells list all depths ifdifferent(erample-3Ca 200'aui2Q100) construction to the following.
10.Static water level below top of casing: Go (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
12.Well construction method: 01W .
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le,auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cenr,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Water Supply&Injection Wells Injection Wells: In addition to sending the form to
Q the address(es) 'above, also submit one jccpy of thus form within 30 days of
13b.Disinfection typ Amount: Z p 6'ji completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016