GW1-2022-05608_Well Construction - GW1_20220610

1 ontracto o ation:
.14:.WATER ZONES :1 '
Well Contrac Name FROM TO I DESCRIPTION
934�— fL ft
ft ft I
NC Well Contractor Certification Number
� 15:OUTER:GASING,(fac multi-rasedlwells) IiII`IEI2(if"aP,licahh:)'�:�::'.:,::'•.`.=
Morgan Well& Pump, Inc. FROM TO' DIAMETER THICLOMS MATERIAL
Company Name +1 ft fL 6 1/8/ ! in' sdr21 pvc
S l6.-Dz ER GOR•TU&TI`rG.
2.Well Construction Permit#: FROM I To I DIAMETER THICKNESS MATERIAL
List all applicable well consbuctionpermits'(ie.UIC,Cowttg State,Valiance,etc)- ft. fL 1 in.
3.well Use(check well use):
M ft. in.
Water Supply Well: 17.-SCREEN',; '::. .' _•.:_ :,:..i.: - '.. �,:': :,i�.' :;'.. .:::° .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERTAL.
J Agricultural DMunicipal/Public ft ft in.;
t i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in•
I Tndustn Commercial J Residential Water Supply(shared)
1 Ini ation FROM TO MATERIAL EMPL_ACHlyuid7'METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL bentonite poured
Monitoring Recovery ft ft
injection.Well
__ ft ft.
Aquifer Recharge OI Groundwater Remediation D/
79:SAND/GRAVEL'PA:. rf a"tcabre
Aquifer Storage and Recovery i Salinity Barrier FROM TO MATERIAL MMPLACEMENT1=01)
J Aquifer Test D Stormwater Drainage ft ft.
i Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer :20.DRILLING.I OG'attach'addition'al sieetsnecess"�' =s --_ •.` >:::'
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock grain size,etc.
c 0 .& 2.0 ft
4.Date Well(s)Completed: Well M# M (45 ft
5a.Well Location: AA ft 5
Y W fgs ft ft I( r'
Facility/Owner a Facility ID#(if applicable) ft fL F /
P ft ft F��'�t.^:� . r�:v�,r.�;;. Url:i
sical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
1S,r1�1��1 O -N .(Q�c`�� w Z6 2Z-
6.Is(are)the well(s)*Permanent or OTemporary Si,, a ed WeR Contractor Date
By sro vno form,I hereby cerirfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or *i No with 15A MCA C 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown well constuction Mformadon and explain the nat re of the copy ofthis record has beertprovided 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 NU BER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3 e@20000'and 1Q100) 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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 n.
(i ) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: _ construction to the following: j
(Le.auger,rotary,cable,direct push,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) 20 Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
/�11\\.�� `-,� the address(es) 'above, also submit:one copy of this fonm within 30 days of
13b.Disinfection typeiV>n11b�"r rw Amount: W., completion of well construction to'the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 222 2016
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