GW1-2022-05618_Well Construction - GW1_20220610

1.Weil Co for an•dd I I
14:.WATERZONES,,'. - .: I-:•':...�..: :r' `.':'...-:.i; :. -
3WellR
cto�e � FROM TO DESCRIPTION
.� ft �t
ft
NC Well Contractor Certification Number
15:OUZER C�ASWG.(foc multi-risea wells)OR IMiFRR(if licahle)'
Morgan Well&Pump, Inc. FROM TO' DIAMETER THIc aims MATERIAL.
Company Name
+1 ft ft 61/8/1 in' sd21 pvc
3 J��l
`' 16.-1'�R CA.SII�TG OR•TIIBING. •eotlierma1•cIo'sed rod`.'.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS ••a ` :`.MATERIAL'
List all applicable well consttuctionpermits'(Le- WC,Courrty,State,Tlariance,etc)- ft• ft, in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17:SCREEN',.:.. `_:. .' .:._:•:;:.,:.• ;,.:'=:.7;;.. r.- :.
FROM I TO I DIAMETER SLOT SIZE THIcEwwS MATERIAL.
Agricultural aMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft
)^ndustxra]�Commercial J Residential Water Supply(shared) -
1 Ini ation FROM TO MATERIAL EMPLACEMENTMETEOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite poured
Monitoring Recovery ft ft
-Injection.Well-
Aquifer Recharge Groundwater Remediation ft ft.
,:19:SAND/GRAVELT.A:CK if a'llcablb
Aquifer Storage and Recovery nSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ~
Aquifer Test QI Stormwater Drainage ft ft.
f Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.tiRILLING.LOG'(attacli additional s�eedfdnecess -'- -_
Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiUrock type,a in s ze etc
It ft
4.Date Well(s)Completed 1 D '!�Well ID# 1 2.0 ft d ft
5 Well Location: O ft ZZC ft-
ft {QiJr1l�
��Yal�► ft
Facility/Owner Name Facility ID#(if applicable) ft.
ft ft
P Address,City,and Zip �UP kk
ft
rzr,County Parcel Identification No.(PIN) .K
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
-SS. 1.229 -N 80. W 5 Zg
6.Is(are)the well(s)J@Permanent or OTemporary Szwzfhis
f Certified Well Contractor Da
B form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or JVNo with 15ANC4C 02C.0100 or 1SA NCAC 01C.0200 Well Construction Standards and that a
If this is a re fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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-I is needed. Indicate TOTAL NL%MER of wells construction details. You may also attach additional pages ifnecessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi$erent(example-3t?a 200'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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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:���L�,
construction to the following:
(Le.auger,rotary,cable,directpush,etc.) .
FOR WATER SUPPLX WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniectio f 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���ay Amount: 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