GW1-2022-03797_Well Construction - GW1_20220404

TrJuA.rAr 1.y1�IfJAACuI.AAV1�1tC( VKU (CxW^l) I korInternal Use Only:
1.Well Contractor Information:
�1n S Nld 14..WATER ZONES
Well Contractor Name d FROM TO DESCRIPTION
qh ft �'Z
�� ft I
z-A
ft ft.
NC Well Contractor Certification Number
15:OIITT&G�ASING.(fni multi=rased'weDs)ORLI13EIt(ifa'lica6Ie)'.�:::',:.:: •.`.d
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICKiIESS MATERIAL
Company Name +1 ft '7 O ft 61/6/ in• sdr2l pvc
�{ � Ifi:Il�R CASING OR-TIIBIIYG. •eother'raal•clb'sed-lod' �� '- "• -
2.Well Construction Permit#: 4-14 w, �z 6 6 q 06 FROM To DIAMETER THICKNESS r MATERIAL
List all applicable well construction permits'(i e.UIC,County,State,Variance,etc.)• ft ft in-
3.Well Use(check well use): ft ft. -in.
Water Supply Well: 17_-SCRIMN. :.r `::. .`•� -. •�_.:: :..:'e:. ;.:�,-.'::;: ,.::: _ ` .-:
NROM TO DIAMETER l SLOT SIZE THTCKNOS I MATERIAL.
AgriculturalMunic paVPublic ft ft
!Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared)
Irri ation FROM TO MATERIAL Y EMPLACEMENT hfETHOD&AMOUNT
Non-Water Supply Well: a ft 20 ft* bentonite poured
Monitoring "Recovery ft ft
Injection Well: ft ft
AquiferRecharge �GroundwaterRemediation
Aquifer Storage and Recovery O Salinity Bairier I FROM OVEL PACK MATERIAL
4 EMPLACEMENT METHOD
L"Aquffar Test E3Stormwater Drainage-erimental Technology Subsidence Control ft ftthermal(ClosedLoop) !Tracer thermal(Heating/CooIing Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,saiUrock a grain size eta)
�.ft ft J
4.Date Well(s)Completed: r —ZZ Well ID# 3 ft 66 ft
5a.Well Location: ft b ft
1 //a ae ft. ft. il
Faciliitty-/OwnerN a Facility ID#(ifapplicable) ft ft
ge ztoga ft
t
6 Physical Address,City,and Zip ft ft
�r't✓lc�Jvl O�/J�3 '21c�2V2JARTIC:_
County Parcel Identification No.(PIN) APR _
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.
al►b�. gps
35.(42 56�57 -N -SI•K36S�a W
6.Is(are)the well(s) rmanent or OTemporary Signa a of Ce d Well Contractor Date
By signing this form,I hereby cer4jy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Lj'Yes or to with ISANCAC 01C.0100 or ISA MCA 02C,0200 Fell Construction Siandardr and that a
Ifthis is a repair,frII out known well construction information and erplain the nature ofthe copy afthis record has beery provided to the well ow�rer.
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•ofwells construction details. You may also attach,additional pages ifnecessary.
' drilled: 1 SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: I�� (ft) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'and 2@100) construction to the following.
10.Static water level below top of casing: :30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" _ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) f 24b.For.lniection Wells: In addition to sending the farm to the address in 24a
�A 12.Well construction method ! r LI above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(r.e.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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 form within 30 days of
13b.Disinfection type: ('Inlwi'i& Amount: 6 a'2 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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