GW1-2022-08545_Well Construction - GW1_20220907

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1.Well Contractor Information:
c7a�1 -'odc�i J� 14:. �TERzoNEs -
Well Contract Nor earn FROM TO DESCRIPTION
15� -01 ft I ft
NC Well Contractor Certification Number
15:OUTER:C9SnN(s,(focmniti-rasedwelLs)OJtL•IIKM if•_.linable';:•::::•.:••.'.:
Morgan Well &Pump, Inc. FROM TO' I DIAMETER I THICIfNFSS I MATERIAL
Company Name +1 6 1/el sd21 pvc
7� /� 16.'INNMCASINGOR•TQBING.' eotlierma7clu'sedloti": r
2.Well Construction Permit#}: L` FROM TO DIAMETER TBICTCiESs MATERIAL
List ag applicable weA construction permits'(>_e.UIC,Cow4v,State,Variance,etc). R ft in.
3.Well Use(check well use):
ft ft. in.
17 SCREEN',:.:.:'.. :.� :.•., r.i �'.:�- :.._;.- : :
AinaiTstriali(Commercial
ater Supply Wen: r....•. .... ...
FROM TO DIAMMTA SLOT SIZE TAiCKNESS MATERIAL.
Agricultural omunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) in.
45= it J Residential Water Supply(shared) _-;,a.-..:.,,_s . • - -
::18:GROUT-.'-..
I lsi ation I FROM TO I MATERIAL I EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery & ft
Injection Well:
ft ft
J Aquifer Recharge I GroundwaterRemediation ;
Aquifer Storage and Recovery 1=1 Salinity Barrier : OS�ND/GRAVEL PACK rfTO I �a' a :=. `- 'XERIAL MWLACEMENT`MEMOD
_Aquifer Test J3StormwaterDrainage ft fL
t Experimental Technology ©ij Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRIILINGLOG'(attaclisdditionalsheetsifaecess -j': =;.FROM TO DESCRIPTION(colar,hardness,solUrock type, srze,ett-)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) \ .
4.Date Well(s)Completed:� aWell ID# ft p f. Sa2"
Sa.Well Location: Gb B it 1 0 f i-l'o
aa l (J KT-\ ? Q ft ft e &i�-
Facility/Owner Name Facility ID#.t(if applicable) ft ft
�/D^ � 9 C.
W/'.66Ur D� ft ft 4.4a. 5
Physical Address,City,and Zip ft ft
J_SF/
County Parcel Identification No.(PIN) <-.UQ0 i':=cw.,- Ut4r1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tf well field,one flat/long is sufficient) yy�� // 22.Cer' ti0n Q.
0 'N OL."�� �� W #V i
6.Is(are)the well(s) 1Permanent or ©ITemporaly Si tore of Certified Well Contractor Date
1'y By signing this orm I hereby c that the wells was were constructed in accordance
f - certify () (were)
7.Is this a repair to an existing well: []Yes or JI No with 15ANC 4C 02C.0100 or 1Stl NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out brown wER construction iXformadon jnd''ezplain lie nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of thisform. 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-I is needed. Tndicate 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: zoo (f) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(e c=ple-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection FVeIls: In addition to sending the fog to the address in 24a
12.Well construction method: r 0"N above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpush,eta) construction to the following:
Division of Water Resources,Underground Injection Control Program,
L13b.Disinfection
TER SUPPLY WELLS,ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
d(gpm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
7 y� the address(es) 'above, also submit one'copy of this form within 30 days of
type: a o � Amount: / V completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2 22 2016