GW1-2022-05822_Well Construction - GW1_20220609

1.Well Contractor Information:
1,07 Ad J�'
Well Contractor Name FROM TO DESCRIPTION
ft ft I I
4- M ft
N Well Contractor Certification Number
� '15:OU�ER:G�ASING,(fni•multi-rasedlweDs)0�2 L•'[blE]2 rf a'livable•..:�r2:.:c'•.`.:
Morgan Well&Pump, Inc. FROM 1 TO. DIAMETER I TBICams MATERL3:'
+1 ft. ft 6 118/1 m' sd21 pvc
Company Name
/��� Ifi: IIQER CASING OR TUBING. eotiiertnE cl6sed
2.Well Construction Permit#: FROM TO DIAIv7ETER THICKNESS MATERIAL ^
List all applicable well construction permiis'(r.e• U7C,Couniv,State,Variance,eta)- ft in.
Well Use(check well use): ft .ft in-
Water Supply Well: 1�"SCREEN'.= : `_ =•:.:_ :,,:. ::- :.':::.;r.' :.:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
.._Agricultural OMunicipal/Public ft M in.
Geothermal(Heating/Cooling Supply) OResideatial Water Supply(single) ft ft in.
I Industn Commercial I Residential Water Supply(shared)
-GROUT-.`..` .. .,:...
[Aquifer
tion FROM TO MATERIAL - EMPLACEMENT METHOD&AMOIINT
ater Supply Well- a M 20 fL bentonite poured
oring Recovery ft. ft
n.WeII: ft ft
er Recharget Groundwater Remediation
�, ;.-19:S,&ND/GRAVEL•PACK if a•'livable
r Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT iMETHOD
r Test 13Stormwater Drainage ft ftmental Technology Subsidence Control ft ft
rmal(Closed Loop) Tracer :20.tirmal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardneu,soiUrock type grain 57ze etc)
V ft ft
ICCO
TS r
4.Date Well(s)Completed: ?Well ID# ft 4 ft �l�
Sa.Well Location:
ft ft n
A-Co, L2!2eNon 19 14 ft %
Facility/Oyw�nerNaamfe Facility
M##(ifapplicable) ft ft
f �1 U? ft ft
Physical Address,City,and Zip ft ft
County Parcel Identifi�tion No.(PIN) U I v -2 O 2 2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) j 2 22.Cer• • n• Dga'lZ' .OG
6.Is(are)the well(s)OPermanent or OTemporary Signa ofCertifled We ntractor Date
By signing this form,1 hereby cer4zfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with 15.4 NC4C 020.0100 or,15A NCAC'01C.0100 Well Construction Standards and that a
Ifthis 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#11 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 Iand surface: . v (ft-) 24a. For All WeHs: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(imample-3Q200'and 1Qa 100D construction to the following.
10.Static water level below top of casing: 4o (ft) Division of Water Resources,Information Processing Unit,
..0'water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 2 7 69 9-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y LI construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY 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 SuppIy&Iniection Wells: In addition to sending the form to
(^_ �J the address(es) 'above, also submit one'copy of this form within 30 days of
13b.Disinfection type: G Amount: -( . 0: completion of well construction to the county health department of the county
where constructed. f
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2 22 2016
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