GW1-2022-03780_Well Construction - GW1_20220404

WA. Ulj UU1NN'FK 1 JUJ'.[ON RECORD (GW-1) For Internal Use Only:
I.Well ontractor Information: I`
1 ty fi I
�cwy 2:� L V obs -14:.WATZRZONES .I_
Well Contractor Name FROM TO• DESCRIPTION
b(C'15S ^ ft ft f
ft ft
NC Well Contractor Certification Numbet is:OU2'ER,GASING,(foc multi=risea*ens) 77N
OR R.R gvia 'licabley-V
Morgan Well&Pump, Inc. \ FROM TO' DIAMETERS TJUCMNIESS MATERIAL
Corn an Name 1 +1 ft ft 61/S/ in' sd121 pvc
P Y I'I
16:7NNER CASING OI2•TUBIl�G:'•eotfiermal'cIo'sed-rod"
2.Well Construction Permit#: FROM To DIAMETER I TMCOQESS r MATERIAL
List all applicable well construction permits d.e WC,Cotariy,State,Ymtance,etc.)- ti ft ?r'•
3.Well Use(check well use): ft it in.
JAgricultural
er Supply Well'
FROM TO_ 4 DIAMETER~;"SLOT SIZE 'TFffCKNMS MATERIAL
lMunicipal/Public ft ft in.i
othermal(Heating/Cooling Supply) esidential Water Supply(single) ft ftustriah/Commercial Residential Water Supply(shared) :.;,• :,:.::• ;:.,:;.. .
[Aqulfer
tion FROM OUT TO ". MATERIAL - EMPLACEMENT&JETHOD.&.SMOTJNT
ater Supply Well: o ft 20 ft bentonite- poured
oring Recovery ft ft
n Well:
er Recharge oCnoundwaterRemediationer Storage and Recovery Salmi Barrier t3 FROM TO MATERIAL RMFLACEMENT METHOD
er Test 0storin—ter•Drainage ft ftmental Technology J3Subsidence Control ft ftrmal(ClosedLoop) 1ITracerrmal eating Coolie Return FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,eta)
g ) Other(explain under#21 Remarks) ft av ft h r
4.Date Well(s)Completed:1 Well ID# ft 60 ft 4, -Ie
5a.Well Location: ft �� ft S�
16rnckS ft o ft �.
.{�G
Facility/Owner Name y Facility ID#(ifapplicable) O ft 6 ft
q06 'PCV k, t
ft ft
Physical Address,City,and Zip ft. ft
'�IoUa�,� 388 o fy _ ,� M .A ....-
• ;�e
County Parcel Identification No.(PI q) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR
- (ifwell field,one lat(long is sufficient) I '
p 2
,Tel 2.Certlfica
N go.7Sq Wn•
nt or J Temporary Signature of Certified Well Contractor Date 6.Is(are)the well(s)Oermane
By signing this farm,I hare-by certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ayes or RIN_ with 15.4 NCAC 02C.0100 or 154 NCAC 02C..0200 Well Construction Standards and that a
Ifthis is a repair ffl out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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 if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS ;
9.Total well depth below land surface: V (ft-) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths iif di•#erent(example-3 a 00'and 2@100) construction to the following.
10.Static water level below top of casing:_ ) (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Centex,Raleigh,NC 27699-I617
11.BorehoIe diameter: 6 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
Y L� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method r
(i.a auger,rotary,cable,directpush,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
[13b.
R WATER SUPPLY WELLS-ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
a the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection type: /lfn.La�/ Amount: bt completion of well construction to the'county health department of the county
where constratted.
i
Form,GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016