GW1-2022-05609_Well Construction - GW1_20220610

I.Jell ContraTctor Information:
__Tmt ` u 14:.D�ATFd2 ZONES:'. r -'- :.: :r';....'•':'..._,,i;
Well C rName FROM TO DESCRIPTION
ft ft `
ft ft
NC Well Contractor Certification Numbei
15:OUTERGiASING,(fo`rmulti-coedwebs)Off£LIPIER ifa.licahle v:•::
Morgan Well &Pump, Inc. I DIAMETER I TRIMgEss MATFxIAL
Company Name /J +1 ft• LOO<Z ft 1 6 1/811 m• sd,21 pvc
2.Well Construction Permit# ",] 16.�R CASING OR TUBING. •'e'ottie-r•ma7 closed-lod'
FROM TO DIAMETER THIcicros MATERIAL'
List all applicable well construction permits'(L a WC,Cououv,State,Variance,etc.)- ft ft in.
3.Well Use(check well use): f- R• in.
Water Supply Well: 11"SCREEN',.:. :::.:. .`�; ._•_ '.,;'-,:'::.;:- j "t:;.. .:::` .-
FROM TO DIAMTEA SLOT SIZE TMCKWESS MATERIAL
Agricultural E3Municipal/Pubhc ft ft in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft in.
1nduslrlal/Commercial i Residential Water Supply(shared) ej8:GROUT•::•..fN
tion FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
ater Supply Well: 0 ft 20 ft bentonite poured
toling Recovery ft ftn.Well: ft ft
er Recharge OI Groundwater Remediationer Stor age and Recovery oSalinityBarrier _ OOMAERTAEMPLACEMENTMETHODer Test StormwatrDrainageft ft.
imental Technology Subsidence Controlermal(Closed Loop) Tracerermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type in s ze etc)
-
O ft ft
' 2tS ft
4.Date Well(s)Completed:"l f d''� Well ID# ft SJ
5a.Well Location:
ftr1d5ft
fc ft ,5F_ • �?' „L
Facility/Owner Name Facility ID#(if applicable) fL ft. '
ft. ft J U N 1 0 202
sical Address,City,and Zip ft ft
ng
�✓ Y G
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cations:
N W
6.Is(are)the well(s)JjPermanent or OTemporary Sign of rtified Well Contractor Date
By s rung this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Lj Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standmds and that a
Ifihis 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 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
cbnstrnction,only 1 GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: t1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J G D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f Idi•$erent(example-3( 00'arrd 2@100�
(_ ir`U 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.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the forth to the address in 24a
L� above,also submit one copy of this lform within 30 days of completion of well
12.Well construction method:
construction to the following:
6-a.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
I
13a.Yield(gpm) Method of test air pressure 24c.For Water Suunly&Infection Wells: In addition to sending the form to
1 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type AlakYI Amount: ot, completion of well construction to the county health department of the county
where constructed_
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources •i Revised 2 22 2016