GW1-2022-08502_Well Construction - GW1_20220503

— rcr .. . I For Internal Use Only:
I.Well Contractor information:
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•14:.FdATER ZONES;'. r �'.l.:•r.:�:i''-.,.
Well Coats[o ame FROM To I DESCRIPTION
ft
NC Well Contractor Certification Number
l '15: 'li OU2'ER:CASMG.(fnc multi rised weILs OR LUJER(tf a
Morgan Well&Pump, Inc. FROM TO' DIAMETER 1 THIr'tc�rFec MATERIAL
Company Name +1 ft ft. 61/8/ ia' sdai pvc
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3 7�/�� 16.DWM CAMNG OR.TI7BING:(•eutlie-rmal d6'sbd-lo /b' :
2.Well Construction Permit#: FROM TO. DIAMETER ! 1 THICKNESS I MA77MAL
List all applicable well construction permits'(r e.UIC,Co-iv,State,Ymiance,etc) ft ft. in.
3.Well Use(check well use): ft ft in.
UAgdculturai
upply Well: 17_"SCREEN',:, - '� _ ; �:':;;•;?.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Muaicipal/Public ft ft in.
rmal(Heatiag/Cooling Supply) ®1Residential Water Supply(single) ft ft in.
ial/Commercial" E3Residential Water Supply(shared)
>'YSrGROUT•::•.. .. = r/.c._;..:
{Irri ation FROM TO MATERIAL EMPLACEMENT METHOD! _4MOUNT
Non-Water Supply Well: 0 fL 20 fL bentonite" poured
Monitoring DRecovery ft %
Injection Well:
ft.
Aquifer Recharge KI&oundwaterRemed ft.
r.
Aquifer Storage and Recovery MSalini tY Barrier SAND/GRAVEL•PACK if a"1!661b ?:...•_ ..r '..'•: '% '":`
FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test UStormwater Drainage ft ft.
!Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) OTracer :20.DRILLING.LOG-(att Eli-idditioualsheetiafaecess 7'�' '•:'=s
t Geothermal(Iieating/Coolinglleturn) J Other(explain tinder#21 Remarks) FROM TO D CRIP ON(color,hardness,soiUrock type,grain size,etc`
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4.Date Well(s)Complete,161-M Z' Well ID# K_5�4)
ZJ ft � 1 `—
Sa.Well
Location: I�r ft.
a ft d rJ S
Cst C f S w,.
Facility/Owner Name Facility M#(if appli able) ft. ft. a
O/� 6 .0 It � (?� .9le ft ft ri' R.,
P4 Address,City,and Zip ft ft M
-13
OL� g :21iR7MARKS _County Parcel Identification No.(PIN)
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I{.:IrYifillvl t�1i ff M.�'a�;rl
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
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6.Is(are)the well(s) (Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify fy that the we1Z(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with 15.4 NCAC 02C.0100 or 15A NC4C 02C•.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: ' 1 ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(ermnple-3Qa 200'and 2/)00) construction to the following.
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (-oY L� - above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test air pressure 24c.For Water SupuIv&Injection Wells: In addition to sending the form to
�, I Qom, the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: l `� Amount: v"�- completion of well construction to the county health department of the county
where constructed_
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Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016