GW1-2022-08146_Well Construction - GW1_20220907

. 1.W ontractor motion: I N
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Ia:.PyATER ZONESc. ;
Well Co are FROM TO=11B1CR71TIO11r
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NC Well Contractor Certification Number ys,O -GASIN(r,(i or riiniti�ased wens b%L•IId&R ¢"p acahtn-y
Morgan Well &Pump, Inc. FROM TO' DIAMETER TSICICi ESS MATERIAL
rw +1 ft ft 61/a/ sd,21 pvc
Company Name 3 tL.L
Iti'I`II�It CASING OR•T1JB7NG. "eotfie'rmalrlo'sed lon _
2.Well Construction Permit#: FROM TO DIAMETER THICEQ9FSS MATERIAL'
List all applicable well construction permits'(ze.WC,County,State,Mu iance,etc.)- ft' ft
3.Well Use(check well use): ft fL
I'L-SCREEN'.=�.: 'r• .. :.•. -_ ..••..• .'.:.- �;.:•�- .�.. ...
Water Supply Well: FROM TO DL4NIECER' SLOT SIZE -TAICIQiESs MATERIAL.'
Agricultural MMunicipaUPublic ft fL tr•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL im.
I in Commercial ID Residential Water Supply(shared) .18:GROUT-.*,.- :: _.:; _-::''.•''`'s::.`=' :::`'-":'
fGeotheimal(Heating/C
tion FROM TO MATERIALater Supply Well: 0 ft 20 ftbmionDe, poured
oring Recovery fL ft.
n.W-eII: ft ft.
er RechargeGroundwater Remediation :.19:SAND/GRAPEL'PA2I �a licaSli er•Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
r TestStormwater Drainage fL
mental Technology lSubsidence Control fL
rmal(Closed Loop) Tracer -. ' 'i::FROM TO DESCRIPTION(colorhardness,sciVrocktype,;;insae,etcrmal(Heating/Cooling Return) J Other(explain under#21 Remarks) ILft
4.Date Well(s)Completed 30 ell ID# IL ft. L�
Sa.Well Loratio c) ft ft✓
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Facility/OwnerName Faciii M#(ifapplicable)'I ft ft
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1l /\L fL fL
sicalAddress,City,and Zip �1i & ft - . ur,c
o� 041 !I 2L RFM6RTCR' `y" e:Yii._9•.t s' ,.:' 71
County Parcel Identification No.(PIN)
5b.Latitude and longitude.in degrees/minutes/seconds or decimal degrees:
(rfwell field,one laf/long is sufficient) a_;22;?
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N w 1
6.Is(are)the well(s) Pernmanent or QlTemporary Sigaa f rtified Well Contractor ate
B fining is form,I hereby certify that the well(s)was(were)constructed accordance
7.Is this a repair to an existing well: 0 Yes or SNo wulr 15A C 02C.0100 or 15.4 NCAC 01C:0100 ilrell ConsL uctian Standards and that a
Ifthis is a repair;fill out known well consn•ucdon information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 412)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: 1145 (ft-) 24a. For All wells' Submit this form within 30 dayS of completion of well
For multiple wells list all depths ff different(example-3 t@200'and 1Qa 100D construction to the following.
10_Static water level below top of casing: d (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection'Wells: In addition to sending the fnmm to the address in 24a
( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A LI construction to the following: i ,
(Le.auger,rotary,cable,directpusk etc.) J ',
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a Yield(gpm)_ Method of test air pressure 24c.For Water SuDD1y&Infection 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 OZ completion of well construction to the county health department of the county
where constructed.
Revised 2 22-2016
Form GW-L North Carolina Department of Environmental Quality-Division of Water Resources