GW1-2022-05611_Well Construction - GW1_20220610

1.WContractor or a'on: I I
b 14..WATER ZONES
Well Conlrac&Jnie - FROM I TO DESCRIPTION
^^ ..� fG ft I .
w ft ft.
NC Well Contractor Certification Numbet M1
15:ODZER-2ASIIZG,(fbc mnlif-casea wells)b t LT1IER if_.licable)':,
Morgan Well&Pump, Inc. FROM T DIAMETER TMCM''i M" MATERLAL
Company Name
+1 ft. ft 61/81' m.' sdr21 live
16'h�IIQER CASING OBTDBIIiTG.� eotfiefinffi-closed-lod` '`:"='•=' ':%''•'• ''
2.Well Construction Permit#: FROM I TO DTAMR.= TmCKNESs MATERIAL
List all applicable well construction permits(l.e.UIC,Cow4v,State,Variance,eta)- ft ft in-
3.Well Use(check well use): fr- ft. in.
VAgdcultural
upply Well:
� FROM TO DIAMETER SLOT SIZE THiCKNFSS MATERIAL.
DMuaicipal/Public ft ftermal(Heating/Cooling Supply) NResidential Water Supply(single) ft ft in.
n Commercial J Residential Water Supply(shared) GROUT::.
1 ILTI ation FROM TO ,MATFRTAL R0r ACEMVNTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonfte poured
'•Monitoring Recovery ft ft
Injection.Well: -
Aquifer Recharge E]Groundwater Remediation
Aquifer Storage and Recovery Salmi Bamer •.�:SAND/GRAVEL If a:'iicabre ..::.. _::: '::..'•: ':
t3 FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater•Drainage ft ft
_Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) Tracer :20.7)RTILINGLOG'(attacbsddiflorial sheets fiecess"�' =s :-
c Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock ty e B02!niz,�el�l
fL
NrN
4.Date Well(s)Completed: 2 Well ID# 5 T
�2 �tJ' ft 3r ft �
5a.Well Location: �jS ft. Yjjhb ^�
ft. ft 'v ra.6,Facility/Owner Name FacilityM#(ifapplicable) ft ft•
ft ft.P sicalAddress,City,andZip ft ft In{OiFi,t4101 r
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. cation'
/Z-2-
6.Is(are)the well(s)4IPermanent or OTemporary Sg e fMOM,
ed Well Contractor Dati
Al; • ring th 1 hereby cer*fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or J§No with 15.4 NCAC 02C.0100 ar 15A NCAC 02C:0200 Well Construction Standards and that a
Ijthis is a repair;fill out known well cansnucSon i?i mad and erplain the not re ojthe copy ofthii record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform. 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'of wells construction details. You may also attach additional pages if necessary.
drilled: % /�., SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aU depths ifdierent(example-3 a 00'and 2@100) construction to the following.
10.Static water level beIow top of casing: (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.) (( 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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:
(ie.auger,rotary,cable,direct push,eto.)
FOR WATER SUFFIX 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&Iniection 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: NSL Amount: a completion of well construction to the'county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016