GW1-2022-08418_Well Construction - GW1_20220503

I-Well ontractor Information:
14:.WATER ZONES-,'. _
well Contra ame FROM TO DESCRIPTION
ft. ft.
ft ft-
NC Well Contractor Certification Number i
15;OUTFR,QASINGA&multi-'rased*611s OR LUG if a'licable'=1
Morgan Well&Pump, Inc. = FROM TO., DIAMETER THICKNESS MATERIAL
Company Name +1 ft- 61/8/ in. sd21 pvc
/�► 16.71�tER G OR•TUBII�G: •eotlie'rmsl•clo'sed-loti' ''::."-..- '._r. . .' .
2.Well Construction Permit#:_?02�-6b wq FROM To DIAMETER THICE2MS MATERIAL
List all applicable well constructionpermits•(r.e.UIC,COW4y,State,Variance,etc)- ft ft. in.
3.Well Use(check wail use): ft• ft in.
1'A-SCREEN.:r.. : :_ : .,. r ;. .
Water Supply Well.. Mom TO DIAMETER SLOT SIZE ^TALCKNESS •MATERIAL.
Agricultural 014unicipal/Public ft it. in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in•
I Tn3ustn Commercial J Residential Water Supply(shared) :.:,.
:18r GROUT-.'-. •
V"To'-V
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: o ft. 20 ft, bentonite poured
itoring Recovery ft. ft
Injection Well: ft ft
_ Aquifer Recharge O Groundwater Remediation r..
Aquifer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ql Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) 1ITracer :20.tiR1LLING.DOG(attar}i=additionalslieetslfaecess -
Geothermal(Heating/Cooling Return) j Other(explain under#21 Remarks) FROMI TO I DESCRIPTION(o1or,hardness,sail/rock type, in size,etc.)
d.ft. to ft
4.Date Well(s)Completed --� Well ID# 0 ft. ft
3c ft ft
X5 Well Location: ��j C�, � •
W L311�.7Va 1 ft ft
Facility/Owner Name
._w,A Facility M#(ifaapprlicable) �i ft ft
qSpYL �iA wl ft ft
P4-Nhysic`allAddresss,,City,an ip ft ft
ae
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,oneellat/long is sufficient) d 22.C cation: .27
3S N �Q , 1 b W I '
Pr o� 2'
6.Is(are)the well(s)OPerro rent or Temporary Si o ertified Well Contractor ,
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or JMNo with 15A MCA C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair;fill out known well construction idformation and explain the nature a he copy ofthis record has been provided to the well owner.
repair under#11 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: OW (ft-) 24a..For All WeIls: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@200'and 2 100) construction to the following.
10.Static water level below top of casing:_(Q (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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,directpus.h,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 3 tIt- - Method of test: air pressure 24c.For Water Supply&Injection 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 typpy ,_ Amount: 33 e'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 .ry Revised 2 22-2016
r
i
I