GW1-2022-06253_Well Construction - GW1_20220701

1.W ontractor 7.nf lion:
•14:01TER ZONES
Well Co for ame FROM ft ft TO DESCRIPTION
� ft ft.
NC Well Contractor Certification Numbet
15;OUTER:CASWG,(foY mnlfi=rased wells)OR L kt PIS
'licahle)'1:::'.:
Morgan Well &Pump, Inc. FROM TO DIAMETER T>�crsvass MaTERTnz
+1 ft 61/81 in' sd21 pvc
Company Name _•_..
w�] �/ I6.�II�R CASING OR•TIIBING. �eotIierma7'closed-lod' : a <.=
2.Well Construction Permit#: JL -`Tro FROM TO DIAMETER THICKNESS r~pATERIAL. ~
List all applicable well construction permits'(Le.UIC,Cow4v,State,Mmiance,etc)- ft• ft. in.
3.Well Use(check weIl use):
ft ft in.
Water Supply Well:
17.-SCREEN',= f::. . �:'.: _:_:.:;:.t:.•i ',::(,. :..z.
FROM TO DIAMETER SLOT SIZE TAiCKNESS 1vIATERLIt.
__Agricultural �MnnicipaLTublic ft ft in.
Geothermal(Heatiag/Cooling Supply) A@Resideatial Water Supply(single) ft - fc in.
i rndus�Commercial ':Residential Water Supply(shared) „Y8:GRODT::. __ '; '":•;'-' - _
[Aq
tion FROM TO MATERIAL - EMPL_kCEMENTMETHOD&AMOUNT
ater Supply Well: o ft 20 ft bentonite• poured
oring Recovery ft. ft
n.We]I
�-,� R ft
er RechargeFCuoundwaterRemediationerStomageandRecoveryISalinityBarrier FROM TO MATERIAL EYPLACEMENTMFTHOD
r Test Q1Stormwater Drainage ft ft
mental Technology Subsidence Control ft ft.
rmal(Closed Loop) OTracer :_ .rmal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type gra n s ze etc)
4.Date Well(s)Completed:�IM Well ID# 120 . ft Q ft.
5a Well Location:
ft ft
ft ft a
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft'
C. 2 f, ft.
_
Physical Address,City,and Zip ft ft
��� '21:REMARKS' `:l- =�x,._sxo..'•.�°.7r .:'ir'=t�`:.t�A.:'A:.�°:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweIlfield,one lat/longissuB�cient) 2 er cation
2 GZ�I'] J�6,r�.,yrt 24 2�
��n L�sN ?O. W �O
6.Ls(are)the wells) Permarrent or OTemporary Sf rtMed Well Contractor Date
81 g is form,I hereby cer#fy that the wells)was(were)constructed in accordance
7.Is this a repair to an mdsting well: 0Yes or #jNo wnli 15A N C 02C.0100 or 15A NCAC 02C-.0200 YMell Construction,Standards and that a
If this is a repair,fell out known well construction ififormatfon and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back ofthfsform. 23.Site diagram or additional well details'
8.For GeoprobeMPT 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-I is needed. Indicate TOTAL NUNMER bf wells construction details. You may also attach additional pages if necessary.
drilled: t1 SUBMCTTAL INSTRUCTIONS
9.Total well depth below land surface:1500 (ft.) 24a. For All Wells: Submit this foam within 30 days of completion of well
For multiple wells List all depths Lrn7fferent(example-3@-?00'and 2@100D construction to the following.
10.Static water level below top of casing: 4 S (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 Ir L� above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,eta) '
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)- Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
n the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typr Amount:_ (r completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmenta!Quality-Division of Water Resources Revised 2-22 2016