GW1-2022-08576_Well Construction - GW1_20220503

(is W-1) I For Internal Use Only:
I.Well Contractor Information:
�� C1 L"SQ
14:.WATER ZONES
Well L SName OM TO DESCRIPTION
f b �
NC Well Contractor Certification Number ft. I
15:oum-G%ASING,for rnniti=cased`yells)b_L7I 12(if a'licsbley-el
Morgan Well&Pump, Inc. FROM TO. DIAMETER l THICKNESS MATFuTex.
Coin an Name /�/� (� +1 ft ft 6 1/8/ rn' sd,21 pvc
p y 16"D2Ug0RCASINGOIt•TIIBIN'G. '6theimalclb'se3lod`
2.Well Construction Permit#: (J J J {{V FROM TO. DIAMETER ! THICKNESS MATERIAL
List all applicable well constructionpermits'CLe.UIC,County,State,Variance,eta)- ft ft in.
3.Well Use(check well use): ft ft in.
Vupply Well: 17:SCREEN',.:.:. .
ltnral OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 0Municipal/Public ft ft in.
rmal(Heating/Cooling Supply) RResidential Water Supply(single) ft ftial/Commercial E3Residential Water Supply(shared)
rAquif�r
tion FROM TO MATERIAL EIVIPLACEMENTMETH5D_ .AMOUNT
ater Supply Well: 0 ft 20 ft bentanite poured
oring Recovery ft ft.
n Well:
� ,� ft fter Recharge Groundwater Remediation19:SANDIGRAVEL'PA rf a er Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test [3Stormwater Drainage ft ftimental Technology OSubsidence Control ft ftermal(ClosedLoop) OTracerFROM TO DESCRIPTION(colo,hardness,soUtrock e, in sia,etc)
ermal(Heating/Cooling Retain) r-il Other(explain under#21 Remarks) ft A> ft rV
4.Date Well(s)Completed: —uZ Well 1D# J ft J ft. a)V �,r
52.Well Location: J ft —)D ft. s ws1 brw_
f al-e Fey,Tl e-! Q ft 1 6 ft
Facility/OwnnerNName ( / F�tyM#(if applicable) V ft. ft N1� ;/o, ;4—e
ros 1 r l`�+ l..�e U�' ft. ft
Physical Address,City,and Zip -71 ft ft M r ',. k_ __
°Wkr.— V 7y `21tI2$MARKS' _ - ':,-
County Parcel Identificati`onNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L9 1
(ifwell field,one t lat/lo g is sufficient)3 ROn � N g�. � 22.Certification: PrXEM, UN7 r1 �1�1
�I (� W l Ll cA�+-,
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor to
By signing this form,I hereby cvlijy that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or OI Io with ISA NCAC 02C.0100 or ISA NCAC 02C-.0200 Mell Construction Mandm-ds and that a
Ifthis is a repair fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#2I 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:—��0 V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdifferent(example-3@200'and 2 00) construction to the following.
I0.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 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: L� above,also submit one copy of this form within 30 days of completion of well
(I.e.auger,rotary,cable,deectpusb,etc.) J
construction to the following: •i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underg round Injection Control Program,
1636 Mail Service Center,,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this fort within 30 days of
13b.Disinfection type: A Amount: 6� 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 222 2016