GW1-2022-07271_Well Construction - GW1_20220809

L Well Contractor Information:
14:. ATER ZONES - ik-_ '...•�:. ::`:....`.':'..._:.i:
Well ontractorNameU IFROM I TO I DESCRIPTION
fl-
NC Well Contractor Certification Number S11
'15:OUTM-CASING,(for multi4'doea wells)O
Morgan Well & Pump, Inc. FROM 'LII�TFI2 if'"lieallIe)',�
To' DIAMETER THICMWSS MATMUAL
Company Name +1 fttok4 ft 61/811 in' sdr2l pvc
P Y �2.WeIl Construction Permit ! � � � O�^ � 16:"INNEIt GOR•TDBII�G: 'eotliermalrlu'sed-loti' '=••_' '•::
#: I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permitf'(L e,LUC Cowuv,State,Ya fance,etc) ft fl. I in.
3.Well Use(check well use): & in.
JW�ater Supply Well: 17 SCREEN'• r _ _ ;r.
icultural FROM TO DIAMETA2' SLOT SIZE TAiCKNESS MATEFSAL _
�MunicipaUPublic ft ft
thermal(Fieating/Cooling Supply) idential Water Supply(single) ft ft in.
Inndus�Commercial J Residential Water Supply(shared)
IIIi ation FROM TO MATERIAL -• EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 & 20 ft. bentonite'' poured
Monitoring Recovery & ft.
Injection Well:
ft ft
J Aquifer Recharge �—t Groundwater Remediation
19:SAND/GRAVEL'PACK If a"lieable
Aquifer Storage and Recovery MSalinity Barrier VR
TO MATERIAL EMPLACEMENT D�THOD
Aquifer Test aStormwater Drainage ft!Experimental Technology Ij Subsidence Control ftGeothermal(Closed Loop) Tracer G_ OG-(atticlisddition'sli Geothermal(Heating/Cooling Return) ,�Other(explain under#21 Rematics) TO DESCRIPTION(color,hardness,soiUrotk e, in size,etc.ft
4.Date Well(s)Completed:y Well ID# k4 t ft aft
5a.Well Location: /� Q 60 ft.
S"y/ K /�'�.0,l,/ fL ft
Facility/Owner Name — Facility M#(ifapplicable) f ft.
� G j ft It
P11y;icalAddr�iry, 'p ft ft
County Parcel Identification No.(PIN) Q U r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
urm
(Lfwell fie`ldryo�ne longitude.
()at/long is sufficient) ,c'�� 22 ratio : �4�,J(�f�� '
'N �� V'��"���.LJ W —I I 10-�J�
6.Is(are)the well(s)�,�'(Permanent or Oi Temporary Siwature ofCerlifi4J Well Contractor Date
By sioQnM this form,1 hereby ceraYfy that a well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or u7No with 15A NCAC 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair•,fifl out blown wdl constructon information andeXplizin the nature of the copy ofthii record has been provided to the yell 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 wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 1v,
For multiple wells Gst all depths if different 3Q200'and 2QI00�
(ft) 24a. For All Wells: Submit this form within 30 dayt of completion of well
(example-
construction to the following.
10.Static water level below top of casing: L"! o (ft) Division of Water Resources,Information Processing Unit,
If water level is above cash;,use "+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Injection 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
construction to the following:
(Le,auger,rotary,cable,directpusi;etc.) 'I•
Division of Water Resources,Underground Injection Control Program,
[FOR WATER SUPPLX WELLS_ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
air ressure i
a.Yield(gpm) Method of test P 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit onelcopy of this form within 30 days of
b.Disinfection type Amount: 1 f(�Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22 2016