GW1-2022-06172_Well Construction - GW1_20220701

I.W ontractor •mation:
14:.W.&TER ZONES
Well Con for acme, FROM TO DESCRIPTION
417 f/n�` ft ft.
ft $
NC Well Contractor Certification Nmnbet
` IS:OU�ER:CASING,({oi mid cased weds)012LIIQER(rf-'livable)';:::'.:
Morgan Well &Pump, Inc. FROM TO' DIAMETER TSICM\Ess MATERIAL
Company Name +1 ft ft- 61181 m' sdt21 pvc
n 16.71�IIvTER GOR•TIIBII�G::•.eotfiecina7•closed-loo`'.`:"="•_' t:%+•'�':, "
2.Well Construction Permit#: ( FROM TO DTdnrETER THICKNESS MATERIAL"
List all applicable well construction peFRas'(Le WV,Cowriv State,Ymiance,eta) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.'SCREEN',i:.. `_ - . - :':;::- r,• i.:..::: .-.
FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL,
Agricultural MMuaicipa]/Public • ft in
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) _ ft fG in•
I IndustnaUCommercial 1 Residential Water Supply(shared) 'IS'GROUT-.'-. -
!Ini lion FROM TO I MATERIAL II+MPL4CEMENTMETHOD&9MOII1qT
Non-Water Supply Well: 0 ft 20 :f• bentonite• poured
t Monitoling DReGovery ft. ft
--Injection.W-e11:
Aquifer Recharge ii Cu oundwater Remediation ft ft.
;.19:S�LQDIGRAVEL'PACS 1f a"licatireZ.
'Aquifer Storage and Recovery Di Salinity Bawer FROM TO • MATERIAL •. ,EMPLACEMENT=OD -
Aquifer Test 0 Stormwater Drainage ft ft
Experimental Technology nSubsidenre Control ft. ft
Geothermal(Closed Loop) MTracer :ZB.DRILEIIvTGLOG'(attacii additional s}ieefs�f iiecess -j':':; :•trt -_
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remailcs) FROM TO DESCRIPTION(mlo,hardness,soillrock type,gram siz,etc)
c 6 ft 12-0 ft +
4.Date Well(s)Completed: Well M# ft R
52•Well Location: 35 f- ft
&S ,G1570 ft 5 ft
Facility/Owner Name Facility ID#(ifapplicable) R ft. ►YaN{t+t
ical Address,City,UJ Zip ft ft
'dc��O•h ilr7 L ZI:RnraurrG - -:,• -_-
!► -
County Parcel Identification No.(P]N) {R"i0iti£ �1 Pm-,a ;ng Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � ..,''
(rfweIl field,one
lat/long is sufficient) Q/ //�L�Q
35,J ` ' l N gr). 4I 5 2 ra70
6.Is(are)the well(s) fPermanent or Q1Temporary Siva e .6 ./!?
f ed Well Contractor Date
B sung is form,I hereby vet tify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: �Xes or �No wuh 15AN C 02C.0100 or 15.I NCAC 02C:0200 Fell Construction Standards and that a
Ifthis is a repair,'JIM out known well construction information and esplain 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: W (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells•List all depths if different(example-3(200'and 2@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 castio use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter:_6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (r� above,also submit one copy of this form,within 30 days of completion of well
(Le-auger,rotary,cable,d rectpusb etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, ,
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c•For Water Supply&Injection 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 typ PIAAmount: completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Depa tnent of Environmental Quality-Division of WaterResources Revised 2 22 2016