GW1-2022-05610_Well Construction - GW1_20220610

Contractor tion:
14:.WATERZONES;'.
Well Co or Name FROM TO DESCRIPTION
rzw ?z, A
NC Well Contractor Certification Number I.
15:OUTER:CASIl�TG,(ioc multi=raged v ells)Oft TTNTR(tfa"licihle)'
Morgan Well &Pump, Inc. FROM TO' DLUN1 TER THICKNESS MATERIAL
Company Name +1 ft 61/8/ in. sdi21 pvc
16:1Nt=CASING Ok.TUB114G:' eottierrnal cliff's d-lod
^
2.Well Construction Permit#:•, FROM TO DIAMETER THICKNESS r ,MATERIAL'
List all applicable well construction permfts rLa UIC,Cows State,Yaiance,etc) ft. I in.
3.Well Use(check well use): ft ft• j in.
i
Water Supply Well: . 17_-SCREEN',
Mom TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipal/Public fc ft in.
I Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft in.
I inndusaUCommercial J Residential Water Supply(shared) ISiGROVT.'
I Ini ation FROM TO ,MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Wafer Supply Well: 0 ft 20 ft bentonite poured
'Monitoring Recovery ft ft
-Injection.Well.: KS"fD/Gllb
ft
_!Aquifer Recharge K3GroundwaterRemediation
VEL'PA CK if a"licabl'e
Aquifer Storage and Recovery DSalinityBarrier O MATERIAL EMPLACEMENTiMETHOD
—I Aquifer Test D Stormwater Drainage Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) Tracer :20.DRILLING.I OG'(attac}i additional sheetsae ess -)''
Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain s ze ete)
r. ft , c ft
4.Date WeH(S)Completed 4�Well IN ft J ft.
Sa.Well Location b IL D R j�j yam.
� ft h ft E V
Facility/Owner Name Facility ID#(if applicable) ft �.•7 ftft. fL
al
Address,Address,City,and Zip ft ft - - - ,, 4._
P viv'f�i✓1 'i'., ut s. Ui j
' `^ :-IL REMARKS f'f' 'x
County v�+l► , Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. cation:
N W
2Z
6.Is(are)the weII(s)*Permanent or OTemporary aSa of rtified Well Contractor Datel
a form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or jWo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siandm ds and that a
Ifthis is a repair,fill out known well construction iriformation 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: 11 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ), (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlerent(etample-I�a(1200'and 2@100) construction to the following:
10.Static water level below top of casing: ?� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.BorehoIe diameter: 6 (in.) (( 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 0 LI above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
FOR WATER SUPPLY WELLS ONLY• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a•Yield(gpm) Method of test air pressure 24c.For Water Supply&Injection iWells: In addition to sending the form to
Z-1-
`^ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:�r a` VVU Amount: 6� completion of well construction to the county health department of the county
where constructed. j
4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016