GW1-2022-03774_Well Construction - GW1_20220404

., .•.i.v<.Vl�I.7J.,L\UI..A�•lll-�'x(jtj(rU, ' � ((�W �� I For Interndl Use Only:
L Well Contractor Information:
014:XATER ZONES;'.WellContractorrNaame �^ TO DESCRiPTtON r
L'S' 'C)- A-
ft.ft ft
ft ft. I
NC Well Contractor Certification Number
15:OII7ER:QASING,(io"r multi=cisedl cvelLs)OR TAR(if'a'licahIe)' ?:.::'•.".:
Morgan Well&Pump, Inc. FROM TO' I MATERIAL
Company Name +1 ( ft I 11 1 ft. fi 1181 m• sdr21 pvc` \ 1G."INNER C:4SING 012•TUBDVG.'�e6thefimal c1o'sed-rod' =•
2.Well Construction Permit#:_ J FROM TO DIAMETER TMCKMS `• MATMUAL'
List all applicable well construction permits'r.e UI,Cotmty,State,Variance,etc.)• ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17_-SCREEN', •t•_ -
.VROM TO DIAMETER SLOT SIZE .•THICKNESS 141ATERTAL
Agricultural i MuaicipaUPublic ft ft in,,
!Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in. !
I Iudustrial/Commercial J Residential Water Supply(shared)
I
tion :GROUT•.':FROM TO MATERIAL EMPLACEME_rd=OD& MOUNT
ater Supply Well: p ft. 20 ft. bentanite: poured
toring Recovery ft. ft.
n Well: ft. ft.
er Recharge �Cnoundwater Remediation er Storage and Recovery Salini Bamer :.�:SAND/GRAVELPACK if ii `Hckbl'e FROM TO MATERIAL EMPLACEMENTMETHOD
er Test QIStormwaterDrainage ft ft.
imental Technology Subsidence Control ft ftermal(Closed Loop) Tracer :20:DRMIM4G.LOG'(atticli'dditional slieedJfiieces's-"-;rmal(Iieating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRI TION(color,Pardnem,soiVrock type,grain sup,etc.)
2 ft. Im ft. r
4.Date Well(s)Completed:) Well m# ft ft
5a.Well Location: ft l ft. �
�.t f en �►-Mg�Jvl,rc Re I^e _7"j ft o� ft 7� g onu c k_
Facility/OwneerrName / F'a�c]ilit�yID#(ifapplicable) ft V ft
Physical A ddress,City,and Zip ft ft
474rr�S .�,���6'o,S3S? °•z1:zx�n�sRxs;;. .:• - - • ..- ..County Parcel Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �!
(if ell fie one Iat/long is dent) 22.Certification raw P r
t
6.Is(are)the well i Permanent or 0lTempojNo
y Signature of Certified Well Contrac or ate
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 with 15�1 NCAC 02C.0100 or 15ANCrIC 02C�,0200 Well Construction Standmds and that a.
Ifthis is a repair fill out/mown well consU uction iriformationexplain the nature of the copy ofthis 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 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 bf wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
P �o a ft
9.Total well depth below land surface:._ ( ) 24a. For All Wells: Submit this form within 30 dayg of completion of well
For multiple wells list all depths ifdiffer ent(example-3Q200'and 2�a l00) construction to the following:
10.Static water level below top of casing:
T/�U (ft) Division of Water 1esources Information Processing TJni
Ifwater level is above casino use"+" 1617 Mail Service Center,Paleigh,NC 27699-1617
11.$orehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method:
�-('� t above,also submit one copy of this form within 30 days of completion of well
(L — Lp
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
EWATERUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
type: Jr4,1"1G✓ Amount: 16 6Z,- 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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