GW1-2022-07365_Well Construction - GW1_20220808

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1.Well Contractor Information:
two Cu'1 _
14:. ATERZONES
Well Contractor Name FROM TO I DESCRIPTION
ft ft
1 ft ft
NC Well Contractor Certification Number
15:OUZEIZG�ASIl�T�,(focmniti-rasedwells)OJZIIIIEE2(if licahIe)' :::'.:.::'•.'.:
Morgan Well & Pump, Inc. FROM I DIAMETER THICKNESS MATERIAL
Company Name +1 ft ft• 61/8/ in' sd21 pvc
to 16:`1TalEI2 Ci1SII�TG OR•TIIBING. 'eotlier'msl•cto'sed.-lud` �.'.::."='•_' t;%.� ' :.
2.Well Construction Permit#:_ t ,/ FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits'rLa UIC,Cowgv,State,Variance,ejaJ M ft
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.-SCREEN',
FROM TO•.: -,•DWASTER
SLOT SIZE THICKNESS MATERIAL,
Agricultural �Municipal/Public ft in,
i Geothermal(Heating/Cooling Supply) �idential Water Supply(single) ft R in.
17ndus�ommercial J Residential Water Supply(shared)
•.I>ri on I FROM I TO MATERIAL EMPL.4CEIENT METHOD&AMOUff
Nan-Water Supply Well: o ft 20 ft bentonite poured
Monitoring ORecovery ft ft
Injection Well:
Aquifer Recharge n Cn'oundwater Remediation ft. ft
Aquifer Storage and Recovery t S Barrier FROM
SgND/GRAVEL'PAC I Ma'•livable ':. ':'.;:_'•::•.IEN •',O `:•'
1� �i3' FROM TO � MATERIAL � EMPLACEI19EN1T METHOD
Aquifer Test Stormwater Drainage ft ft
i Experimental Technology 0.8absidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DR1LLIlIG.L•OG'(attiiEadditionals'lieets}t'aeces'si-j':.:'=:`• s
1 Geothermal eating Coolie Return FROM TO DESCRIPTION(colo,hardness,soil/rock e,grain Sia ett)
(H � g ) �Other(explain under#21 Remarks) 't I Liu fL
4.Date Well(s)Completed:��Well ID# 4y 1
". S
5a.Well L ration: ^ ft• R
ft ft
Facilit3/OwnerName v Facility M#(ifapplicable) ft' fL
3 2 w \ ft
Physical Address,City,and Zip ft ft
County Parcel Identification No.(PIN) UNI
1f1#::i'�`""''1", i •-..fir .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3S,-72S 320 N V W
6.Is(are)the well(s)Q�ermnnent or OTemporary Signature of CertifM Well Con to VeTz
By signing this form,I hereby ce)1iify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or �To wR72 ISA IJCAC 02C.0I00 or ISA NCAC 02C•.0200 Well Construction Standards and that a
If this is a repair ftII out known well construction Ldformation and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 4121 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12-0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater le+e!is above casing;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: O Y(r� above, also submit one copy of this form within 30 days of completion of well
construction to the
(Le.auger,rotary,cable,direct push,etc.) following:
FWATERUPPLY WELLSFONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c,For Water Sunuiy&Injection Wells: In addition to sending the form to
��jjthe addresses) 'above, also submit one!copy of this form within 30 days of
Amount: "'1 Q2 completion of well construction to the county health department of the county
where constructed. 4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 4 Revised 2-22 2016
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