GW1-2022-07274_Well Construction - GW1_20220809

O TER zoN FROM
ES Well Co tot• are FROM TO I DESCRIPTION
NC Well Contractor Certification Number it. ft
15:ODOR-LASIN�,(fo"r meth--&i4eH wePs)O tI:IIiLI2 rf-'livable)'.,
Morgan Well&Pump, Inc. = FROM TO' DIAMMTER' THICENFSS MATERIAL
Company Name +1 f '70 ft I 611a/ t m' sdt21 pvc
IrnMMCAS1NG0Ti•TOBII4G. 'e6tliertnalrlo'si:d4o6"l.:`:.,'-**-Z
2.Well Construction Permit#}: //��r I A FROM To DIAAMTER TMCKNESS MATERAL'
List all applicable well construction permits(&UIC,CoUnty,State,Variance,etc)- ft ft. I in.
3_Well Use(check well use): ft .& m
Water Supply Well: 17."SCREEAT'. ?_- .';�' : _ = .,;:'::. ;::�::.`•.:t.-�:;.;
FT2oM To� �• �.D -� SLOT SIZE ,•THICKMS MATERAL.
Agricultural DMuaicipa]/Public ft ft in.
'Geothermal(Heating/Cooliag Supply) DResidwtial Water Supply(single) ft ft
1lnnd ommercial J Residential Water Supply shared -_•,�.._..: .,=..:_ • - r _ r.•_::•.
PP Y(shared) GROUT•. -
fon FROM TO MAT£RTAL - ELOIACEtdENTki TROD&AMOUNT
Nter Supply Well: o ft 20 fL bentonite poured
ringRecovery ft ft.
.Well: ft ft.
r Recharge Groundwater Remediationr Storage and Recovery i S Bawer sty FROMrTest DStormwaterDrainage ft. ftental Technology Subsidence Control ft ftrmal(ClosedLoop) 11Tracermal eating Coolie Rturn Oh FROM To DESCRIPTION(color,ha:dnez,soiuroex e s;a,ear(A a g ,) ) (explain under#21 Remarks) 0 .ft t S ft _1 .
4.Date Well(s)Completed: \ Well M# 5. ft 35 ft Ni
5a.Well Location: 3S. ft 6 ft Q(k
11po
it-Sto
ft
Ilk
Facility/Owner Name Facility lD#(if applicable) ft ft. ,o "
132 alibi I�lo�►11 gall I ft ft s � _
Physical Address,City,and Zip ft ft AUG
- :.:-_ �4T::j,.-t_.-,:.: :::_�,.:::•: -
14tficrarl o� Przn504 sZ
county PaselIdentificationNo.(PII� g Ural
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it'well field,one lat/long is sufficient)
2 ration:
6.�52 -N %-7?2Jq W 7
6.Is(are)the well(s)Vermann or DTemporary Sign ttified Well Contractor Dat
.vno is form,I hereby ce#5,than the',weH(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or igNo w th 15.4 C 02C.0100 or ISrl NCAC 01C,0100 F7eH Construction Standards and that a
IJthis is a repair,fill out brown well construction information and exphrin the nature of the copy of this record has beoiprovided to the well owner.
repair under 421 remarla 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:__ tl SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 52P (ft-) 24a. For All Wells: Submit this form within 30 dayt of completion of well
For multiple wells fist all depths ifdierent(example-3 a 00'and 2@100) construction to the following.
10.Static water level below top of rasing: O A) Division of Water Resources,Information Processing Uiait,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) t 24b.For Injection Wells': In addition to sending the fait to the address in 24a
r L{ above,also submit one copy of this form;within 30 days of completion of well
12 Well construction method
construction to the following:
(Le.auger,rotary,cable,direct push,eta)
i
EWIATERDPPLY WELLS ONLY Division ofWater Resources,Underground Injection Control Program,
1636 Mail Service Center,RRaleigh,NC 27699-1636
Method oftest: air prsure 24c.For Water SuDuly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this font within 30 days of
typ Amount: 2Zori 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 Revised 222 2016