GW1-2022-08620_Well Construction - GW1_20220503

1.Well Contractor Information: �
14:.WATER ZONES
Well Contra torName FROM TO I DESCRIPTION
T� ft ft
ft ft
NC Well Contractor Certification Number
15:OU�ER,CASING,(formNti=rasedwe]is)OItL7IQEI2ifa'ticahle'•^;:::'.
Morgan Well & Pump, Inc. FROM TO' D1AMZTER THICIf1iTE55 MATERIAL
Company Name +1 ft. 3 ft 6 1/8/ I in, sdf21 pvc
rj�� 16`INNER C 4SIIvTG OR TUBING.' eotliermal closed lod' '�'
2.Well Construction Permit#: {�w �f�f "r FROM TO DIAMETER TBICKNESS MATERIAL
List all applicable well construction permits'(Le,WC,Cowitx State,Yatitmce,eta). tt• R m.
3.Well Use(check well use): ft ft in.
Water Supply Well: 11:SCREEN*:-:. .
FROM TO DLAMF.TER SLOT SIZE TFfrCKNFSS MATERIAL.
_Agricultural DJ Municipal/Public ft ft
Geothermal(Heating/Cociag Supply) Oi Residential Water Supply(single) ft ft
I?ndustn Commercial J Residential Water Supply(shared) 18:GRODT•::,_ -
I l,ri ation FROM TO MATERIAL I EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* bentonite poured
°Monitoring OR—very ft. ft
Injection Well: ft ft
J Aquifer Recharge Groundwater Remediation :1y.SAND/GRAVEL
if a"lica6le "
Aquifer Storage and Recovery OSalinityDarder FROM TO MATERIAL EMPLACEMENT METHOD
—I Aquifer Test OStorrawater Drainage ft ft
J Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer :20.DRMEING.LOG'(ittai:li'sdditidngs*Neetsifneces's-"
1 Geothermal(Heating/Cooling etum) J Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness,soil/rock ty a in size,etc)
�FR611
ft rz a;r 4 ,4.Date Well(s)Completed: Well m# �ft. ft' UJ ;f7
52.Well Location: p� T/� &0 ft / e{ ft. r b\e f
Facility/ wnerName FacilityM#(if applicable) ft ft
q5 q b f tr1l&5-t ��s 'i � ft ft.
Physical
/Address,
City,and Zip ft ft
_L.� ill' 1 wJ'�./✓� `Z1cR :MARKR°- - `:�- _ _ _ _'-r,.' .(.�,
County Parcel Identification No.(PIN) P .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.C tion: ,
-L-5s_-4 N 8 1 , 37126� W . . '
6.Is(are)the well(s) Permanent or OTemporary Si, ture of Certified Well Con Actor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M Yes or O,No with 15.4 NCAC 01C.0100 or 15A NCAC 01C,0100 Well Consruction Standards and that a
Ifthis is a repair fill out known well construction information and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under 421 remarks section or on the back of this form. I
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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100) construction to the following.
10.Static water level below top of casing: —/ (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.) f 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r 0 r L1 above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) 'CO� Method of test: air pressure 24c.For Water Supply&Injection 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: �,�( t/Jj� Amount: e? 01 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
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