GW1-2022-03791_Well Construction - GW1_20220404

..i:+ii+a..v1�t.7AatUt.11V1`I1[1�L,V1CUIk-TW-1) IPorintemaluseUniy:
1.Well ontractor Inf, tion:
Y f •14:.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
n `7Sft '• f. ft
_�JA ft ft
NC Well Contractor Certification Number
� '15:OU7.'ER,eASINO,(foc multi=erseilwells)OI2LIIgE12(if a'licahle)'-;:�::`.:,::'•.`.:
Morgan Well&Pump, Inc. FROM TO' DIAMETER I THICFfiVFSS MATERIAL
Company Name +1 ft 614
ft. 6 1/a/ , in sdr11 pvc
47
�p {�+/`��/` 16:IlNII�R CASING OR•TQSIbIG.''eothecmal closed lod'?,'.:."=';'
2.Well Construction Permit FROM TO DIAMETER THICHNEss I MATERIAL
List all applicable well construction permits'(r.e.U1C,County,State,Variance,etc.)- ft• ft in.
3.Well Use(check Well use):- ft ft. in.
Water Supply Well: 17_-SCREEN', :s::. .' _.; =•_•'_: ::?•' :_ �.: `•:,•":::.:. ..::' .-:
kROM TO DIAMETER~: SLOT SIZE THICKNESS MATERIAL.
Agricultural OM cipaMblic ft ft
11ndustrial/Commercial
Geothermal(Heating/Cooling Supply) ' esiderrbal Water Supply(single) ft ft in.JDResidential Water Supply(shared) :xS:GROUT::, "' _:,?".'.•:'-
In1 ation FROM TO MATERIAL - EMPLACEMENTMETHODaAMOUNT
Non-Water Supply Well: 0 ft 20 ft, bentonite poured
Monitoring DRecovery ft. ft
Injection Well: ft. ft.
� i
AquifesRecharge E_4Cn'oundwaterRemediation r• ,
�;�, .19:S�DID/GRAVEL'PACK if a"licalile •' - .. :.•. ,..•.
'Aquifer Storage and Recovery MSalinityBarrier FROM TO MATERIAL EMPLACEMENT METH OD
Aquifer Test Q!Stormwater Drainage• ft ft
-_i Experimental Technology OSubsidence Control ft ft
Geothermal(ClosedLoop) DTracer :20.tiRILLING.IOG'(attailli=additiorisls7ieetsifaecess"')::{' :•:'=; _':;.:':'
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,WDrock type in size,etc.)
ft o ft C\
cu
4.Date Well(s)Completed: '6-1-7-Z Well ID# 3 F. ft ft. . eA
52.Well Location: ft • 66 ft �r 9
J
ft ft
Facility/Ownerr�Name Facility 1D#(if applicable) ft ft
L
%� l3 ft ft �'• a
Physical Address,City,and Zip J ft. ft
liCLrl�l'•J ... �2'FM:dRKC"�:'.,,.._...:J. - _ _.t,_ _ ..4 -
County Parcel Identification No.(PIN) A,r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lone is sufficient) 20 ^3 22.acatio ✓,✓`-3�;i� Pi�i I
7� .f'Ui�i'IcSr
6.Is(are)the well rmanent or ©ITemporaly Siena a of Cert' 'd Well Contractor Date
By signing th' arm,I heeGv cer4ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M'Yes or I with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Iffhis is a repair fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional Well derails:
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.TotaI well depth below land surface: zoo (ft.) 24a. For All Wells: Submit this form within 30 dayg of completion of well
For multiple wells list all depths if different(example-3 a2OD'and 2@100� construction to the following.
10.Static water level below top of casing: �j(} (ft-) Division of Water Resources,Information Processing Unit,
Jfwater level is above casino use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in,) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t above,'also submit one copy of this form within 30 days of completion of well
12.Well construction method: O Y LI construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
tho - 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /U Method of test: air pressure 24c.For Water SuDDiy&Infection Wells: In addition to sending the form to
��tt the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 916-1 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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