GW1-2022-05820_Well Construction - GW1_20220609

I.Well Contractor Information: I I
14..WATER ZONES-,'.
Well Contract rName I FROM I TO I DESCRIPTION
.} ft &
ft ft.
NC Well Contractor Certification Number
ODTER:QASING',(foi•multi=rased weIls)OR IS�TE1t tfa''litahie'3:�:::•:: .'.:
Morgan Well&Pump, Inc. FROM TO. DIAMETER THIC�cc MATERIAL
Company Name
+1 ft' ft- 6 1/8/I m' I d2l pvc
S�? �� 16"IlVh2 3R G OB•TUBII�G. eotfiermal closed lode : "=';' :;
2.Well Construction Permit# CP FROM TO DIAMETER THICKNESS MATERIAL'
List all applicable well ronstructionpermits•(r.e UIC,County,State,Variance,etc)- ft ft in.
3.Well Use(check well use): ft. ft. to
17._SCREEN". _ -. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE ^TIirCKNF.SS I MATERIAL.
Agricultural DMunicipal/Public ft ft
!Geothermal(Heating/Cooling Supply) 1i Residential Water Supply(single) ft ft in•
I Inndustdal Commercial _Residential Water Supply(shared) :i18r GROUT.'
!lsi ation FROM I TO MATERIAL - EMPLSCEMENTMET ffn&AMOUNT
lGeothennal
ater Supply Well: 0 ft 20 ft benionite poured
oring ORecovery ft. ft
n.Well:
�—,� ft R
er Recharge 0I Groundwater Remediation r
r Stora e and Recove g ry OSalinityBamer FROM TO MATERIAL E,�LACEMENTMETHOD
r Test DStormwater Drainage ft ft
mental Technology Subsidence Control ft ftrmal(Closed Loop) !Tracer :20.DRMUNG.LOG'(zttic dditidn'al seeedifi ecess '�'�;(Heating/Cooliag Return) r-ji Other(explain under#21 Remarks) FROM TO DESCRRIIPTION(color,hardness,soil/mck type in size,ete.)
r _ O ft ft- fed
) p Z5— � r
4.Date Well(s)Completed: S ell ID# fc ft r�-�n
Sa.Well Location: /� at' ,6 Pft
�V y �� ft ft
Facility/Owner Name Facility M#(if applicable) ft ft
i "0 ft ft
i
Physical Address,City,and Zip ft ft ^"
(77 V4S-�O' l
6
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiffwCell field,one lat/long is sufficient) v1 +i
1 ) � N s���0 22.Certification:
2 �` fd
W 2Z
6.Is(are)the well(s)tPermanent or OTemporary Si turc dCergWed Well eontractor Date
�,(� By signing this form,1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: �'Yes or lli.IINo with 15A NCAC 01C.0100 or 15A NCAC 01C,0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthii 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-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3(22000'and 1@I00) construction to the following.
10.Static water level below top of casing: J y (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 D/L- l 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 �'Q'��L� above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpush,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Un3ergronnd Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
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: )�� Amount:Cp "� oe L 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
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