GW1-2022-07273_Well Construction - GW1_20220809

7a14:.WATER ZONES
well Co for ame FROM TO I DESCRIPTION
r n ft ft
ft.
ft.
NC Well contractor Certification Ntmbet
'15:OVXKP•LASING,0er multi-casea weIls)0 LUJER and'h'aihle)',
Morgan Well&Pump, Inc. FROM TO* DIAMETER mcmms I MATERIAL
Company Name no +1 fL t 61/a/ k m sdr21 pvc
n ( 71 16�II�ER OR•TUBII�G. eotliermal clii'se3lod : "" °
2.Well Construction Permit#- FROM TO DIAMETER' THICKNESS MATERIAL'
List all applicable well construction ermits Le R fL
app' p ( ,Cowutq State,Ymiance,eta)•
3.Well Use(check well use): ft ft. in.
6
. 1�SC12F�EN•,::. . - _ :.. . .:. r ..-••_+.:f.: ". .: :
Water Supply Well: - . :•r:..•.••._ ,,.._,:....•... �....•. .:-.
FROM I TO DIAMETER .SLOT SIZE I TMCIt MS MATERIAL.
Agricultural 13Municipal/Public R ft in-'
Geothermal(Heating/Cooling Supply) ffiResideatial Water Supply(single)
1 9 �•
1 Commercial Resi i ft
dential Water Supply(shared) GRODT::. _ -
,::
fn
on FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
ter Supply Well: 0 ft 20 ft bentonite poured
ring Recovery ft ft.
Weil: ft ft
r Recharge �J Groundwater Remediation . -
19:SgND/GRAVEL'PACK tf a"licafile :.C..
r Storage and Recovery Salinity Barrier FROM TO • MATERIAL E-Y2LACEMENT N=OD
r Test OStormwater Drainage ft ftental Technology Subsidence Control ft ftrmal(Closed Loop) Tracer e. rmal Meating/Cooling Return) J Other(explain undea#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroek type grain s a etc)
4.Date Well(s)Completed:_( 1 ZZ Well ID# W R 5 ft
ft Qej) ft
Sa Well Loca'On: V``�� klyawn
ft ft &
Facility/Owner Name Facility ID#1(ifapplicable) ft ft �1 r-.• P
L MO �o ft �,
Physical Address,City,and Zip ft ft ( r
County Parcel Identification No.(PIN) Ih •i dfi 1 �1`^.wVgS.i (JR#
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 cation
35 Ngo.7S�3 W42,
6.Is(are)the well(s) Permanent or ©jlTemporary Signa f rtified Well Contractor D
het
B gning is form,I herebv cet tr,fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or f No wul!154 C 02C.0100 or 15A NCAC 01C,0200 McLl Construction Standards and that a
Ifthis is a repair fill out known we➢consb•uction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#121 remarks section or on the back of thisform 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdiierent(ermnple(3@200'and 2Qa 100D construction to the following.
10.Static water level below top of casing: `y (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: 7n 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,directpush,eta)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) O Method of test: air pressure 24c.For Water Suppiv&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: 2.4 oz completion of well construction to the county health department of the county
where constructed.
I
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 222 2016
l