GW1-2022-06174_Well Construction - GW1_20220701

1.W ontractor I •mation:
14:.WATER ZONES ;
Well Co for ame, FROM TO DESCRIPTION
ft
�J ft
c//nee,� I ft ft.
NC Well Contractor Certification Number
15:OUXZ---PU?ASWG,(fo`rmniti=raseawells)ORTr-R(if iicahIe)'.,
Morgan Well&Pump, Inc. FROM TO" DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 04 ft 6118/ ' h' sdr21 pvc
16`aIIUR CASING OR•TUBING.(•eetlier'rasl cla's@d--100-••
2.Well Construction permit#: FROM TO DIAMETER THICKNESS MATERIAL-
list all applicable well construction permits z e UIC,Cow4v,State,Variance,etc-)- ft• ft m-
3.Well Use(check well use): ft• it. in.
Water SnppIp Well.. FROM TO DIAMETER SLOT SIZE THICKNESS rMATERIAL.
. ,'Agricultural QMunicipal/Public ft ft. in.
!Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in•
!rndustria]/Commerciai i Residential Water Supply(shared) OUT•:: .• .• _ _ - -
r21
[Aq
tion FROM TO MATERIAL - EMPLACEMENTMETHOD&AMOUNT
ater Supply Well: o ft 20 ft. bentanite• poured
oring Recovery ft ft
n.WeII.
er RechargeI GroundwaterRemediation . . _ . •er Stora e and Recov i Salmi Basler S2M1GRAVEL-PACK rf a'iicibre ':.:;._-.:-:...._ .: •..:-
g exy ty FROM TO MATERIAL EMPLACEMENT METHOD
r Test Q!Stormwater Drainage ft. ft.
I Experimental Technology E33ubsidence Control ft ft
Geothermal(Closed Loop) KITracer :20.DRIISINGDOG(aifaciiaddi[ion'slslieetsjfiiecess 7'_' `•t=s --
i Geothermal(Heating/Cooling Retain) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sere,etc.) '
4.Date Well(s)Completed Well iD# ft ft
5 ft ft
hell Location•• � ��.3?�)�o N � 5 ft D ft-
Facility/Owner Name�,�/ Facility
yE #(ifapplicable) ft 8� ft.
�Q.�f`r• fib i.I1�srm Air,as 14 h ft ft
Pl=icai
Address,ds,6ity,and Zip J ft_ fL 17
V��\ �`V I��, -2L•l2YtMARTCC= `:J. .a�"�.-Pi .:�4:.%' ,'rr:• a:..a�:Ec
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or der_imal degrees:
rf•well field,one lat/long is sufficient) 2 ration {fl'vii`f i c-C i
C d, q Q Q _ ��� � .r� Ln;i
35. � 6rl "N G o.s( (�9 r,t11Q,!6
�: v.r i:'•Q1
W
6.Is(are)the well(s)*Permanent or Q!Temporary Sigma e f ed Well Contractor Datef
B o sine is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Xes or �No wuli 15A C 02C-0100 or 15A NCAC 02C.0200 MeH Construction Standards and that a
If this is a repair,fill out known well construction information and explain Ale 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 weJls construction details. You may also attach additional pages if necessary.
drilled: . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `�(� (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For meduple wells list all depths ifdifereni(example�e--3@200'and 2@100) construction to the following.
10.Static water level below top of casing: [7V (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
11.BorehoIe diameter: 6 (in.) f 24b.For Injecton Wel1S: In addition to sending the form to the address in 24a
12.Well construction method: r0�1 L{ above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpusil,etc.) J
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-I636
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 thus form within 30 days of
13b.Disinfection typ Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016