GW1-2022-08526_Well Construction - GW1_20220503

.. vly tC1'�l V1CJJ llrW-1) I For Internal Use Only:
1-Well Contractor Information:
14:.WATER ZONES
Well ontraaccttoorrNam/e FROM IL
� TO\ DESCRIPTION
ft 1l j
ft ft
NC Well Contractor Certification Number
'15:OU7.'ER,G4SING.(fo'r multi=rrsedwells)ORIar_?ER ifa'licahle',^;:�":'.'•::'-.'
Morgan Well&Pump, Inc. FROM I To DIAMETER TMCMNESS 1 MATERIAL
Company Name +1 ft 151 ft 61/81 rn'% sd2l pvc
�3���� 16:TNIQER CASING 012-TIIBING.'•eotlier•�a1•clo'sed-lod•': `�'•;' :•:%-
2.Well Construction Permit#: J FROM TO. DIAMETER ! TMCIQMS MATERIAL.
List all applicable well construction permits'CLe.VIC,County,State,Variance,eta)- ft• ft. m•
3.Well Use(check well use): ft ft• IIr•
VAgricUltural
upply Well 17.SCREEN',:,:.: =`_ - =':':.•i• ;:-. ,,. ..:
FROM TO DIAMETER SLOT SIZE THICKNESS MATLRW..
nMunicipaLTublic ft ft in.
rmal(Heating/Cooling Supply) Residential Water Supply(single) ft ftal/Commercial E311esidentiai Water Supply(shared) GROUT-.'-
FROM TO MATERIAL EMPI4rWMVN'r•h4_E7HOD&.kMOUNT
Non-Water Supply Well: 0 fL 20 ft* bentonite poured
Monitoring Recovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge I Groundwater Remediation .
;19:SAND/GRAVEL'PACK Cf k•116 re
Aquifer Storage and Recovery 0Salinity Bawer FROM TO MATERIAL Mv2LACEMENT METHOD'~
Aquifer Test E3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
II'Geothermal
Geothermal(Closed Loop) OITracer ;20.DRILLfi'G-LOG attacliadditionals&d.IfEeiess--j':'.(Heating/Cooling Return) ril Other(explain under#21 Remarks) FROM To DESC PTION color,hardness,soil/rock type,grain size,etc
[� /l ft ft 'r�
4.Date Well(s)Completed: I Well ID# vv ft-
19 cot,. �,fy
Sa.Well Location: ft ft SqA)r � `-•
IOU
Facility/Ow rName T \ Facility M#(ifapplicable) V ft � ft• ,
c 1\s Of u S4rSb ft ft.
Pliysical dress,City,and Zip ft ft
qsz 13 2I:REIvLARuS `:i' ;ra:� r.
County ParcelIdmtificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or deeimal degrees:
(ifweld,one no is sufficient) q 22.Certification: 'h g
/15b'aa�j -N O 4 6._C)7VzC;-_- 1 W Ar , vri tick .32 1 I
ZoZZ
6.Is(are)the well(s)aPermanent or OTemporary Sidnature of Certified Well Contractor Date
By signing this form,!hereby cerKzfy that the weli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: El Yes or []No with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standm•ds and that a
Ifthis is a repair-,fill out)mown well construction itiformation and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 421 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: % 165 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft
( ) 24a. For All Wells: Submit this form within 30 dayS of completion of well
For multiple we141lst all depths if different(example-3(,200'and 2QJ00� construction to the following.
10.Static water level below top of casing: G/ (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to,sending the form to the address in 24a
12.Well construction method: Lp above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUFFIX WELLS ONLY: Division of Water Resources,Underground Injection Control Program, -
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �O Method of test: air pressure 24c.For Water SuuDly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
m
13b.Disinfection type: J(Gn,Ak( Amount: 6 ey 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 2 22-2016