GW1-2022-08618_Well Construction - GW1_20220503

1.Well Contractor Information:
�c�.6
•1a:.wa.TaR ZONES
Well ontra or�N ft�yame I� FROM TO DESCRIPTION
ft
ft ft I
NC Well Contactor Certification Number
'15:OUTER,CASIfIG,(fo"r raniti•rase i wells)QI2 LII�R i£ 'llcable)'
Morgan Well &Pump, Inc. FROM TO' DIAMETER TRIMNESS MATERIAL
Company Name +1 ft. ©3 ft 6 1161 in' sd21 pvc
J f ^ r/ 16 INNER CA NG OR TCTBING.' eotfie mat clti'sed lode i ''_'
2.Well Construction Perm 0
0 it#: f`f 3 FROM TO DIAMETER THICHNESS MATERIAL
List all applicable well construction permits'r e.WC,County,State,Tlw fiance,eta)• t3. ft. in.
3.Well Use(check well use): ft ft. in-
Water Supply Well: 1VSCREEN `: . .`•�: ...__::: is -'..:::.Y:.;.. ;.- ::.. .:=`•
FROM TO D SLOT SIZE THICKNESS MATERIAL.
Agricultural Muaicipal/Public ft. ft in.
i Geot BResidentialhermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
I rndustrl ]/Commercial I Residential Water Supply(shared) -
:IrrigationIA FROM TO MATERL - EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft. 20 fL bentonite!, poured
Monitoring Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge K3 Groundwater Remediation _ r
Aquifer Storage and Recovery DSalinity Barrier FROM/PTVEL O •• PAS MATERIALe E.WLACEMENTMETHOD
11Geothermal
Aquifer Test OStormwater Drainageft ft
Experimental TechnologySubsidence Control ft ftGeothermal(ClosedLoop) OTracer
(Heating/Cooling Return) [3 Other(explain under#21 Remarks)J
FROM TO DESCRIPTION(color,hardness,soillrock type, in size,etc)
ft 0 ft r
4.Date Well(s)Completed: &o ZZ Well ID# ct] ft vG Q ft
1
5 .WeII Location: ft ft.
eAU On zrtcl a !fit
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft ft
Physical Address,City,and Zip ft ft
L/n
County Parcel Identification No.(PIN) A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AI «
(if well field,one lat/long is sufficient) 22.Certification' 027
..
W
6.Is(are)the well(s)WPermanent or OTemporary Siw a of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: L71 Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair f:II out known well construction information'anaTexplain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 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: I ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: L1 C) (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
O. Y(✓� 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,directpusl-,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) L 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 form within 30 days of
13b.Disinfection type: Amount: I 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 V Revised 2 22 2016
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