GW1-2022-08837_Well Construction - GW1_20220906

ror mrernat use unly.
I.Well Contractor Information: I ,:
-14:. A-TER ZONES
Well Contractor Name FROM TO =I)IISCRIPTION
�5 5'r ft.
--� ft
NC Well Contrador Certification Number
15:OUXIR•CASINCz,(foc multi=riled Wells)OR MU t C>f lieihle)'S
Morgan Well &Pump, Inc. FROM TO' DIAMETER THICKNESS MATRRT-
Company Name +1 ft Q 5 ft. 6 118/ in' sd21 pvc
I I ROM CA13I G OR•TQBING. edtliermaZ'ciri'se3loo" '` :':
2.WeII Construction Permit#: FROM TO DIAMETERTHICKNESS MATERIAL
List aB applicable well construction permits'(ie.EUC,County,State Ymiance eta) f it'
3.Well Use(check weIl use): ft ft m-
f—lAgricultural
er Supply Well: 17.-SCREEN.::: �<'•:•_• _ :,:. :'::.;:-.it,.: ::..
FROM TO DIAMETER SLOTSIZ$ TfSICFCNESS tV1ATERLAL.
CiMuaicipal/Public ft. ft in.
othermal(Heating/Cooling Supply) ' ResidentialWater Supply(single) fy ustn Commercial i Residential Water Supply(shared) ;;18:GROUT -
blaigation FROM TO MATFRTdT. - EMPLACEMENT METHOD&_4MO11NT
Non-Water Supply Well: o f 20 ft- bmt'.nite- poured
Monitoring ORecovery ft. ft.
It
jection Well:
ft ft
Aquifer Recharge Groundwater Remediation
,.'19:SAND/GRAVEL•PACK tf a ptca6lbAquifer Storage and Recovery nSalinityBatier FROM To 'MATERIAL EWL LAt NTMETHOD
Aquifer Test 13StormwaterDrainage ft ftExperimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer :20..MRMUNG.L'OG'(a,fEi `additionaI sbeothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
c ft
4.Date Well(s)Completed: V Y ` y` ell ID# `l] ft �{�j ft t Ito-W-d�
Sa.Well Location: ft vro o ft' (0 V" 1
o ft Ql% ft cow,-,
Facility/Owner Name Facility ID9(if applicable) ft L
Physical Address,City,and Zip ft ft
'R�raRTrc:;.::':��;:- • -1•:..c; 1-. :_ �`�e.t. ,.,y,:-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` tar t r'-
(tf well field,one lat/long is sufficient) 22.Certification'
35-72go S -Ng1. 01-33-G W
6.Is(are)the well(s) (Perms neat or F_4'Temporary Si, tore of Certified Well Contractor Date
l By signing ibis form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: P!Yes or 0 with 15A NCAC 02C.0100 or RSA NCAC 02C:0200 Mell Construction Standards and that a
I•fthis is a repair;ffl out known well constr-uctian information and"erplain the nature of the copy ofthii 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'ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZG (ft-) 24a. For All WeIls: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 a 00'aannd 2Q100� construction to the following.
10.Static water level below top of casing: IS (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27 69 9-1 61 7
II.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C) L` construction to the following:
(Le.auger,rotary,cable,deeetpush,eta) J '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(' m) 2 a 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: D !� Amount: O �•�. 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