GW1-2022-06250_Well Construction - GW1_20220701

I.W ontractor ation:
14:.WATERZONES ;
` Well Co for V FROM TO DESCRIPTION
f/
? ^z' ft. ft.
(J��/ ft. ft:
NC Well Contractor Certification Number
15:OUTER:CASR,?Gxfo7r mnl8=rasea Ps)OR I�TE)2 Crf_.livable}' ;'.::'•.'.:
Morgan Well &Pump, Inc. FROM TO' DIAMETER THICIfiYE55 MATTTAS•
Company Name +1 ft ft 61181' in sdr21 pvc
�. t I r 16.'IITI�I2C• GOlt•TQBING. eotIiermaZ•clase3lod' : ""• ' :';'
2.Well Construction Permit 9• FROM To DIAMETER T•$CENnS MATERIAL' ` ~
List all applicable well construction permits'f e.WC,Cow*,State,Variance,eta)- fir ft• in.
3.Well Use(check well use): R ft. in.
Water Supply Well FROM TO DIAMETER SLOT SIZE 'THICKNESS r14fATERIAL.
Agricultural fit MunicipabTublic ft ft
i Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft
I Zindusiiial/Commercial i Residential Water Supply(shared) -GROUT-.".."
-
fAqm:16r
tion FROM TO MATERIAL - EMPL-4CEMENTMMMEOD&AMOUNT
ater Supply Well: o ft- 20 ft bentonite. poured
oring Recovery ft ft
n.WeII:
�--,� ft ft.
er Recharge nGroundwaterRemediationr Storage and Recovery Salim Bawer SAND/GRAVEL PACK if a"licabre '':ty FROM TO MATERIAL EMPLACEMENT METHOD
r Test 11Stormwater Drainagemental Technology OSubsidence Control ft ftrmal(ClosedLoop) Tracerrmal(Heating/Coolin Rt OthliFROM TO DESCRIPTION(colo,hardness,soillrock type in size,etc)
O ft $ ,/3►,.�W � ,.
4.Date Well(s)Completed: Well ID w ft qO^ i Nw
5a.Well Loc
ation- `- o 't 2.(J✓ ft '�
�a��n.c Vv e�YG✓� I ft ft
Fac"ity/Owner Name Facility M#(ifapplicable) f, ft.
OC, 7-%I ' ft ft.
P�ysical Address,City,and Zip ft
_ ..t....i
:.
County Parcel Identification No.(PIN) I ' RZ •
Sb.Latitude and lonacitndein degrees/minutes/seconds or decimal degrees:
(zfwell field,one lat/long is sufficient
�7 ) 2 er cation: `•'°''1'��
'N tA*S<t A• W
2Z
6.Is(are)the well(s)*Permanent or OTemporary Signa e f rtified Well Contractor Dat
B g ing is farm,I hereby certify rhat the well(s) was(were)constructed in accordance
7.Is this a repair to an exdsfing well: L7'Yes or f No wuh 15A C 02C_0I00 or 15A NCAC 02C-.0200 MeN Construction Standm-de and that a
Iftlus is a repair,fill out known waR construction information and explain the nature of the copy ofihfs 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 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•ofwells construction details. You may also attach additional pages ifnecessary.
drilled: `� SUBMITTAL INSTRUCTIONS /
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this foram within 30 days of completion of well
For multiple wells list a!!depths ifdi�er ent(example-3(�00'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If
water level is above casing;use 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: -In addition to sending the form to the address in 24a
9 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L�
(Le-auger,rotary,cable,direct push,eta) construction to the following:
FOR WATER STIFFLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
f 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a Yield(gpm) �`-� - Method of test airpressure 2¢c.Far Water Suably&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this foil within 30 days of
13b.Disinfection fyp Amount �i 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