GW1-2022-06284_Well Construction - GW1_20220608

1. ontractoor ormation: L I
1 ►J :. -
14:.WATERZONES;'.
Well Co c[ 'Name FROM TO DESCRIPTION
—A ft ft
ft ft
NC Well Contractor Certification Nmnbet
15:OUZ'ER:C4SING,(focmulti edweIls)Q1tTTNRR if'a IMMATERIAL
e'=;
Morgan Well &Pump, Inc. FROM O' DIAMETER TEICK1QEss
Company Name
+1 ft ft 61/811 m' sdf11 pvc
2 _ 1 16"Il�IIIER C' G OR T1IB11�G. 'eotliermaldln'se(l
2.Well Construction Permit4: `(i(Q FROM TO DIAMETER TEaCENUS MATExIAi. ~
List all applicable well const ucilonpermfrs'(Le.UIC,Comity,State,Vm*mce,etc)• ft. ft. in.
3.Well Use(check well use): ft.
ft. I in.
Water Supply Well:
SZ SCREEN'., .: `_:. .`•,: z-'•. :. .' ::.:. .::•`
FROM TO DrAMETER SLOT SIZE THrCKT'ESS MATERIAL
Agricultti al DMunicipal/Public fL fL in.
Geothermal(Heating/Cooling Supply) JIResidential Water Supply(single) ft ft •
Indus Commercial !Residential Water SuJR.�,I)
l (shared) ;:Y8:GRODT:+,."_ _ :• ' - "
1Ini ation FROM TO MATERIAL EM?1ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• bentonite poured
'•Monitoring Recovery ft ft.
injection.Well: ft.
_j Aquifer Recharge Groundwater Remedi ,.Zg:SAND/GRAVEL-PACK tf a"licabl
Aquifer Storage and Recovery �i Salinity Barrier• FROM TO MATERIAL EMPLACEMENT METHOD +
Aquifer Test OStormwater Drainageft ft.
Experimental Technology OSubsidence Controlft ft
Geothermal(Closed Loop) Tracer :ZO.DRILLINGDOG'(attiiili addition'sl sheetslf necers'-
r. Geothermal(Heating/Cooling Retum) J Other(explain under FROM To DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
fD .ft ft lbmoyn L
4.Date Well(s)Completed: 3 n Well ID# 3s ft. ft wfn G
5 W.II Lo tion• '�/� D ft Dft Yi7JM1
J�_r �y-A l►tr ft ft r"� D
Facility/Owner Name�1 �Fa�cility E)#1(if applicable) ft ft �•,
66 1 9'6 1IJ � � l3D\ �L,,�• ALI
ft ft . „
ysical Address,City,and Zip ft ft (1'fonviauon Pr%cew, Uri
County Parcel Identification No.(PIN)
5b.Latitude and long tude in deb ees/minutes/seconds or decimal degrees:
(if well fielil,one lat/long is sufficient) 22_ cation:
35• - 5q 'N $ 4( W 5 Z
Z
6.Is(are)the wells)J@Permanent or [3Temporary Signa yled We}1 Contactor Date
pre
I hetebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or WNo with 15ANC4C 02C.0100 or 1SA NCAC 01C.0200 Well Construction Standmds and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthii 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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft-) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths ifdifferent(example- \v'mid 2 100)
construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wens: In addition to sending the form to the address in 24a
12.Well construction method 0 L( above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLX ONLY: Division of Water Resources,Underground Injection Control Program,
L LS
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 1 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 this foim within 30 days of
13b.Disinfection typ DYXVWfl Amount: completion of well construction to the county health department of the county
where constructed_
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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