GW1-2022-06173_Well Construction - GW1_20220701

1.W oniractn:
or motio
14:.W.ATER ZONES C. ;
Well Co [or ame� FROM TO DESCETPTION
ft ft
ft ft
NC Well Contractor Certification Number
15:OV,CER:G�ASING,(fol•multi-riled we11s)OR IMiER Cif 'licabls)'.y:::'.:•;
Morgan Well&Pump, Inc. FROM TO- DIAMETERI TMCMI S MATERAL.
Company Name +1 ft 162 ft 61/8/ m' sdr21 pvc
16:`IIibTEIt G OR•TIIBING. 'edtliermal'clo'sed--lob"
2.Well Construction Permit#:_ FROM To DIAMETER rmcTaqFlss MATERIAL'
List all applicable well canstruction permits(t a WCG County State,Varian.,etc.)- R• ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17-"SCREEN',.::
FROM 'TO DIAMETER •SLOT SIZE .TfiTC DIMS MATERIAL
Agricultural DMunicipal/Public ft ft in.
I Geothermal(Eeating/Cooling Supply) �I asidential Water Supply(single) ft. fL
1 Industrial Residential Water Supply(shared) _-:r .:.:.•:, :. •.. -•. _ _{ ;..,,•_•;
fN
lionFROM TO MATERIAL EMPL4CY1KE TT'MEZaOD&AMOUNT
ater Supply Well: o ft 20 ft benionite poured
toring Recovery ft fton.Well-
ft ftea•Recharge MI GroundwaterRemediation er Storage and Recovery I Salini Bamer :.19:S2ND/GRAVEL• A:CK rf a"livable! ty FROM TO MATERIAL EMPLACEMENT METHOD
er Test 113Stormwater Drainage ft ftimental Technology Subsidence Control ft ftermal(Closed Loop) (Tracer :. )R1ISSermal(Heating/CooIing Reium) J Other(explain under#21 Remaks) FROM To DESCRIPTION(color,hardness,saiUrocktype grainsarere)
b ft ft
4.Date Well(g)Completed:L�� Well ID# 1 Q, ft ft ,
hFacifflit�Y/0-wmcr
: 3e ft Ll ft
ft ft
IJ Of
Facility ED#(if applicable) ft ft
to
1 ft- ft ;f r t
P�,j'F steal A�d�dyr"e�ss�City,and Zip ^)� ft ft
/II--�/s�\ OIL 1' V�5 °7.Ii"R�R fdRTfC` ':s,:-: -' -_ - _ _ _'C.;.:.::.'::• :.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: nt l'SCR�
Cif wall field,one lat/long is sufficient) 2 j
tion:
6.Is(are)the well(s)*Permanent or MTemporary Signa e ed Well Contractor Date
B p sinform,I herelry cvkfy that the wells)was(wet e)constructed in accordance
7.Is this a repair to an existing well• QYes or yNo wuh JSA 02C.0I00 or J5A NCAC 02C-.0200 F7ell Construction Standards and that a
If this is a s•epair frll out known well consh•uction information and explain the nature of the copy ofthis 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 wall 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'ofwells construction details. You may also attach additional pages if necessary.
drilled: '
p �� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11st a!!depths if ds�erent(example-3 LDD' d 2 an@ 100) construction to the fallowing.
10.Static water level below top of casing: v (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection YVelli: In addition to sending the form to the address in 24a
12.Well construction method: n 11 above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.)
construction to the following:
[FOR WATER SUPPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-163 6
.Yield(gpm) OMethod oftest: air pressure 24c.For Water SuupIy&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit one copy of this foffi within 30 days of
.Disinfection t3rp Amount: 6Z, 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