GW1-2022-06176_Well Construction - GW1_20220701

on ac or -oration: ,
14:.PyATER ZONES
Well Con for ame� FROM TO DESCRIPTION
��� ft ft
' � ft $
NC Well Contractor Certification Number
� '15:OUTER:CASING,(foc multi=6ise3 iWus)OR Tmoa(ira'lirdhle)'1:�::'.:•::'•.'.-
Morgan Well&Pump, Inc. FROM TO' DIAMETER I Tmcla ESs MATERIAL
Company Name +1 ft. ft 1 6 1/S/ in. sdr21 pvc
��'W5�1f 16:DWR.CASINGOR•T0BING'•eotlier'ma'Icln'sed-log`: -`'•_' :•:
2.well Construction Permit#:_ Q - ` FROM TO DIAMETER =CKNFSs MATERIAL' ~
List all applicable well constucttonpermits'(Le UIC,Couttir Stale,Ymzance,etc.)- ft ft. in.
3.Well Use(check wail use): ft ft m
Water Supply Well: 17_"SCREEN',; t:;. . �,:':;•',. �.: ::..:::: ..:
Aglicllltlltal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL..
QMunicipal/Public ft• ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I in _i Residential Water Supply(shared) ..18rGROUT: -
hai ation FROM TO MATFRUL EMPL-4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite• poured
'Monitoring Recovery ft ft
Injection.Well:
ft it
_!Aquifer Recharge K3 Groundwater Remediation
Aquifer Storage and Recovery S Baines :.�:SALID/GRAVEL P2 CK>f a"licaBle = ''?
al�tY FROM TO MATERIAL Eil7PLA=NTMEI•HOD('
_i Aquifer Test 13Stormwater Drainage ft
I Experimental Technology DISubsideace Control ft ft
Geothermal(Closed Loop) Tracer ZO.DRILLIIIGIOG'(attaclisdditiouslseeissfaecess 'j'�;�:•:'=s
Geothermal(Beating/Cooling Return) -i Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type grain size etc)
A ^^ 6ftis 'L iw
4.Date Well(s)Completed: {.� Ll� Well ID# 5. ft 3.5 ft e
rk-
5 Well LocatZffiGs
ft. Sa ft r
So ft. G40 �` u Y'a-rot
Facility/Owner gore Facility ID#(if applicable) ft ft
W f%Z ft n L
Ph al Address,City,and Zip
ft. ft
NYMN
County Parcel Identification No.(PIN) Uri,
5b.Latitude and long tude in deb ees/minutes/seconds or decimal degrees: r;
(ifwell field,one lat/llong is sufficient) n• V��` N �N . 0 6 ( 2 cation:r�W /!J
6.Is(are)the wells) Permanent or OTemporary Signa e f rtified Wea Contractor Wite
B o ring is form,I hereby certzfy that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: '!!Yes or *No wuh ISA N C 02C-0100 or 1SA NC✓_C`02C:0200 F.11 Construction Standm'ds and that a
If this is a repair,fill out known well construction hiformation and explain the nature of the copy ofthis record has beets provided to the well owner.
repair under#21 retnarks 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 of well
construction,only 1 GW-1 is needed- Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBlYffTTAL INSTRUCTIONS
9-Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths ifd fferent(example-323 a 00'mtd 2@100) construction to the following.
10.Static water level below top of casing: V 0 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method �L� above,also submit one copy of this form within 30 days of completion of-'well'
(ie.auger,rotary,cable,directpuslr,etc.) construction to the following:
E:typ
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,PTC 2 7699-1 63 6
Method of test air pressure 24c Far WaterFor Water Su�p1�&Injection Wells:Iniection Wells: In addition to sending-the form to
the address(es) 'above, also submit one copy of this foim within 30 days of
e 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