GW1-2022-03175_Well Construction - GW1_20220307

I.Well Co actor Informatio
•14:.WA.TER ZONES
Well Contractt000rN FROM T I DESCRIPTION
322` A ft ft.
ft ft 1
NC Well Contractor Certification Number
'15:OUTER-eASING,(for multi-caked wells OA L-IIh?ER(if''-'licalrle)'=;:�:i S.::'•'.:
Morgan Well&Pump, Inc. FROM TO DIAMETER TBICIL`rESS MATERIAL
h 21 pvc
Company Name +1 R' V ft' 6 1/g/� in. sd
16."IlVNER CASING OR•TOBING' eothei mal closed lou
2.Well Construction Permit#: 335 FROM To I DIAMETER I THICMESNS MATERIAL
List all applicable well construction permits'(.e.UIC,Comtty,State,Variance,etc.)• ft. ft in.
3.Well Use(check well use): it
It in.
Water Supply Well: M'SCREEN',.'. . .-
FROM TO DIAMETER I SLOT SIZE I.TAICMNESs IMATERIAL.
!Agricultural 014unicipaMblic g• ft in,
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft in
Indus- trial/Commercial l/Commercial J Residential Water Supply(shared) -GROUT .'' ': - `'.- . -
E Irri ation I FROM TO I MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 & 20 R- bentonite poured
Monitoring DRecoveny ft. ft
Injection Well:
ft ft.
_ Aquifer Recharge �GroundwaterRemediation
':19:S6ND/GRAVEL'P9.CK if a "licalill: ...-�.-'� '" '' "': •..
Aquifer Storage and Recovery O Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
s Geothermal(Closed Loop) OTracer ;Z0.DRiLLING.LOG(attadi additional seetssf aecess 'j'
I Geothermal eating Coolie Retum FROM TO DESCRIPTION(color hardness,soil/rock type,grain size,etc.)
(H njg1 ) [3Other(explain under#21 Remarks) R 1
4.Date Well(s)Completed: �+ f�vpVell ID# `5 ft 1 ft
a.W Location 35 ft CJS ft �.
i V gomes 55 ft fj it
F ''tZOwper N me Facility ID#(if lira le) 5 ft Oo ft
�GZ bft • ,c.,
P al Address,
City,and Zip ft. ft
� WI� 21:I2EMARKS' '-b?. ti
County Parcel Identification No.(PIN)
MAR 0 r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) tification• }�"� 7KT3 ;1
Z3 ZZ
6.Is(are)the well(s) Permanent or Temporary goo of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or *No with 15ANCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. i
• 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:_ I l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (t) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'mid 2Q100� construction to the following:
If
f Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Static
level is above casing,use"I,. 1617 Mai]Service Center,Raleigh,NC 27699-16I7
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ror L� above, also submit one copy of this form within 30 days of completion of well
(ie.auger;rotary,cable,directpuslr,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control:Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (�jJ Method of test air pressure 24c.For Water Supply&Injection!Wells: In addition to sending the form to
' the address(es) 'above, also submit one copy of this foam within 30 days of
13b.Disinfection Amount: 10 O2 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
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