GW1-2022-05622_Well Construction - GW1_20220610

1.Well ontrra,=r Info rma-qq
V 14:.WATERZONES:'. � i l:_�'....r•?:r':.,..`.':'..._.-'•
W�n( N /� FROM TO DESCRIPTION
V7f/T�V�j✓1/\ �I �'' ft ft
ft ft 4'
NC Well Contractor Certification Ntmmbet
OU�.'ER,G�ASING',(foc mniti=cased veils)Oft LIIgE)t if _.
Morgan Well &Pump, Inc. FROM T ' DIAMETER THICI�v>ss MATERIAL
4-1 it. ft- 61/8/ in' sdr11 pvc
Company Name �/�.�� / ,•
•L/ (/�_ 16.`�TFS2 G OR TL7BI1vG. •eotlier`malclo'sed-lod" .'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL -
List all applicable well construction permits'(Le. UIC,Cou»tv,State,Pa lance,etc.), ft- ft ! in.
3.Well Use(check well use): ft• ft. i in.
Water Supply Well: 17."SCREEN',:,:. : ::_:. .`� .- _.:._:•;:^:. : ',:-',.: ,:'::;.. r,.: :;.:. .:::° .
FROM TO DWAXT>"R SLOT SIZE THICKNESS MATERIAL.
-!Agricultural DMunicipal/Public ft ft in
:Geothermal(Heating/Cooliug Supply) Residential Water Supply(single) ft ft in.
I Induslxlall ommercial J Residential Water Supply(shared) 18.GROUT.'...
Irri lion FROM TO MATERIAL - EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite poured
Monitoring Recovery ft. ft
Jnj.ection.Well:
�—,� ft ff.
_!Aquifer Recharge t-1 Groundwater Remediation
19:SAND/GRAVEL-PA:W if a"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test OStormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) Tracer ;20.DRILLING.I:OG'(attacb additional slieetUf i ecegs-'j'1:;
I Geothermal(Tieating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCR TIO (cot ,hardness,soiur¢ck tp a gra n sae ern
4.Date Well(s)Completed: ell ID# ft ft
W Il Location:
ft ft
rchIrf,
Facility/Own atnce Facility M#(ifapph�) ft a F:,„
r s Y ft ft r_
Pb Siva!Address,
City,and Zip ZQ I_ ft ft I A I
•� vv if+ --'_-�J.:•r�`'`I: : 202
'.,-.Ci
County Parcel Identification No.(PIN)
JC. l:4 •i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. cation'
'N 8D. 352� W z Z
6.Is(are)the wells)*Permanent or OTemporary S'� ertifi4l ontractor Da
y sie;e�zhLsjbrm,I hereby certify than the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or RNo with ISC 02C.0100 or 15A NCAC 02C.0200 Well Const,vction Standards and that a
If this 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 ofthis 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 NUIvMER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: �O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3 a200'and 2@Z00) 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.) I 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Lp above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,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 SuumIv&Iniection Wells: In addition to sending the form to
D Y K G the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection Amount• completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 2 22 2016 `