GW1-2022-05823_Well Construction - GW1_20220609

1.Well Contractor Information: I I
7o l,q T f 14:.WATER ZONES
well ontracto Name FROM TO DESCRIPTION
ft.
G rT fL
NC Well Contractor Certification Number '
IS;OUTERCASING,(fncmniti edwebs)O_•> if-'licihle'
Morgan Well &Pump, Inc. FROM TO' M DIAETER TBICKNESs I MATERIAL
Company Name +1 ft. fL 6 118/ I in' sd2l pvc
2.Well Construction Permit#:
1 �/�; •��� 16:'ll�I2 OR•TUBII�G.' eotliermal•cio'sed loo`' ''•_' <.'_°'
1 —I FROM TO DIAn7.TER THICEVESS MaTERIAI.' ~
List all applicable well construction permits'(I.e. C,Coway,State,Variance,etc.), ft. ft in.
3.Well Use(check well use): R ft' in.
C
upply Well: 12SCREEN',: `::. . _ :,: ,.:�= .r :,:'::.;•:.:�. ;.:.
FROM TO D SLOT SIZE THTCKNESS MATERIAL .
ltural i Municipal/Public ft ft in.
ermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in
n Commercial i Residential Water Supply(shared) -
fN
lion FROM TO MATERIAL EM2M2Ij CEMENT METHOD&AMOUNT
ater Supply Well: 0 ft- 20 ft* bentonite poured
oring Recovery ft. ft
n.Well: ft ft.
er Rechaz'ge Groundwater Remediationer Storage and Recovery SalinityBarrier oSAND/G oVEL PACK rfaRTIIcaALIeE 4PLACEMENT YIE]0Dr Test QlStormwater Drainage fL ft•
mental Technology Subsidence Control ft ft.
rmal(Closed Loop) OTracer :2B.DRTLLINGLOG(itticYiid1ditidnA1 sheets-ffnecess--rmal(Heating/Cooling Retum) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,ha mess,soiUrock type n s re etc)
. ft /01
fl-
4.Date Well(s)Completed: . ell ID# q 0 ft r j
11 SaMWeIl Location: ft ft VGA
1 '(�/
l 1 fi! Wbf 1 l2 ft 1
Facility/Owner Name Facility M#(if applicable) ft ft
ft ft
Physical Address,City,and Zip P ft ft-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) �pOn PPri•i:tsisz,n Unp
!! DVPXS
��( 22.C lion: ��� ., �
It6.Is(are)the well Permanent or OTemporary SignaKire of Certified Well Contractor Date
By sie ring this form,I hereby ce7lify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or iqNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standm-ds and that a
If this is a repair f111 out known wel7 constr uction information and explain the natru•e of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back ofthisform. 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: ' I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(ft-) 24a. For All Wells: Submit this(form within 30 day5 of completion of well
For multiple wells List all depths if different(example-3 a 00'and 1@100) 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.Borehole diameter: 6 (in.) 24b.For Iniection Wells: 1n 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: A LI construction to the following:
(Le.auger,rotary,cable,directpush,etc,)
[FOR WATER SUPPLXWELLS ONLX Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Yield(gpm) Method of test air pressure 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submitone copy of this form within 30 days of
b.Disinfection type: '51 1 Amount: completion of well construction to the county health department of the county
wheze constructed.
Revised 2 22 2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i•
9
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