GW1-2022-05623_Well Construction - GW1_20220610

1.WeJ Co tractor Information: I I
•14:.WATER ZONES;'.
Well Contrvp4orjame FROM TO DESCRIPTION
n ft ft
(� ft r
NC Well Contractor Certification Number ft
15:OUTER:CASING,(foi•multi-casea wells)bit M Ekt if a'livable's
Morgan Well &Pump, Inc. FROM I T DIAMETER I THICKvi US I MATERIAL
Company Name +1 ft I qT, ft 1 61/8/� m' sd,21 pvc
16.-u* R CASING Ok.TuB1NG. eotIiermal closed loo "''_' ;
2.Well Construction Permit#: L FROM TO DIAMETER . MATERIAL'
List all applicable well construction permits(ie.LU ,County,State,Variance,etc)• ft- ft. in.
3.Well Use(check well use):
ft ft. in THICI4�ESs
i—Agricultural
ater Supply Well: 17.-SCREEN',
FROM TO DiAMETE SLOT SIZE TAiCKNFSS MATERIAL
Oi MuaicipaL/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ftndusl OCommercial !Residential Water Supply(shared) IS.GRouz , -
Ia'i ation FROM TO MATERIAL EN9JL.CEM1iT METHOD&AMOUNT
INater Supply Well: 0 ft- 20 ft bentonite poured
oring Recovery ft ft
n.Well. ft ft.
er Recharge �Groundwater Remediation •.19:SAND/GRAVEL'PACK A a'Rlica6ler Stolage and Recovery SalinityBamer FROM TO MATERIAL EMPLACEI4IENT METHOD
r Test 03tormwater Drainage ft ftmental Technology Subsidence Control ft ft
rmal(Closed Loop) OTracer :20.DRMDNG.DOG'(i ttacli additionalsliee6.jfaecess- ':t'.'-''=trmal(Heating/Cooling Retum) J Other(explain under#21 Remarks) FROM To DESCRIPTION(color hardness,soil/rockty a insizeetc)
b s ft. Ift.
4.Date Well(s)Completed) 111 � L Well ID# r.> ft b ft
5a.Well Location: ` ` 30 f1.4b" ft' qe
R ft
S�x��.�Yna�
Facility/Owner Name Facility ID#(if applicable) ft ft
l�a&50 ban6kA\ 'o�� Y�1 ��ll N 2� ft ft
P iccall Aid\drreessCigy and Zip ft. ft
L�W�` �/�1�.�I�L L— 2Ia2FMARKR'::c'...._..�'_ '. •': .�:... — - _ .
't - -
County Parcel Identification No.(PIN) ' -• r-n a sir
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3 . WaTo N A , GilI W � u
6.Is(are)the well(s)*Permanent or Temporary Sign ofC ed Well ctor Da
lf
rung is orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is thus a repair to an existing well: ©Yes or f No wuh ISA 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out known well construction information and explain the nature of the 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 of wells construction details. You may also attach additional pages if necessary.
drilled: t1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells lint all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 5b (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Aaj*l Service Center,Raleigh,NC 2 769 9-1 61 7_
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the foam to the address in 24a
t 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,direct push,etc.) _
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY!/ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) `v Method of test air pressure 24c.For Water Supply&Jaiectionl Wells: In addition to sending the form to
Q the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type O W Amount: U orz, 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 /