GW1-2022-09227_Well Construction - GW1_20221003

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NC Well Contactor CertificationNurnbet
` IS:OUTER G�dSING,(ioc multi= ea wells 12,721
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Morgan Well&Pump, Inc. FROM -Tom DIAMETER fCompany Name +1 61/8/ , pvc
-21
2.Well Construction Permit#: FROM To DIAMETER�Y! T�ICFSs MATERIAL'List all applicable weIIconstuaSonpamits'(ie.U1C,County,State,Parlance,etc). R
3.Well Use(check well use): R ..t
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Water Supply Well: M SC12EII�T'.: nrntrrt x sioT'STZs •I IMATERIAL;: ;
FROM TO•.• L TAiCFCiZPSS�. •. .
Agricultural []J Municipal/Public ft &
Geothermal(Heating/Cooling Supply) ®@Residential Water Supply(single) ft fL in.
I Cammrrriat Residential Water Supply(shared) - r a-= -=• - ti _"''_
t Ini ation FROM TO MdTi RTdT. EMPLACII�NTM 01)&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonfte• pow
t Monitoring oRecovery it it
Snjection.WeII ft ft
Aquifer Recharge K3GroundwaterRemediation :,. :•:_•.
:.19:SAND/GRAYELTAC$>f a'liraTile -
Aquifer Storage and Recovery DSalmityBawer FROM TO I MATERTAL EMPL7Ct?+�T�NTISETHOD
Aquifer Test []Stormwater Drainage ft ft i:�.i<- ^P^•a
Experimental Technology i Subsidence Control rt "
Geothermal(Closed Loop) Tracer :28.M- R1LLiIQGS0G'(attacli`s3ditiorisl sheefsjf neces-7:::` •=Y .' ' ''
FROM TO DFSCRTPTIO (mtor hardness,son]/rotk e,gr=sia,mfiLT
r Geothermal(Heating/Cooling Retain) -i Other(explain under#21 Remarks) ftft
4.Date Well(s)Completed: Well IN it 5 ,
Well Location: S RP75 ft
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Facility/Owner Name Facility lD#(if applicable) R
P cal Address,City,and Zip A ` ft
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(mfwell field,one laMong is sufficient) �2Zczfion-
�3S. �'7c�� -N 1O.3��t W Z 2?r
6.Is(are)the well(s)*Permanent or ©!Temporary Signs f ed Well Contractor Date
gnino is form,I henebv cen7fy that the weII(s)was(were)constructed in accordance
7.Is this a repair to an existing well. []Yes or f No wuh 15.4 C 02C.0100 or 15A NCAC 02C:0200 FPeII Construction Standads and that a
Ifthi.T is a repair fiII out known weII consbuctfon friformotton and explain the nature of the copy ofz;&retard has been provided to the well owner.
repair under*21 remark;sec>4on or on the bark 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 Iand surface:Soo fft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I ad depths ff different(==ple-33@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casting;use"+" 1617 Mail Service Center,Raleigh,NC 27699-16I7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: 1a addition to sending the form to the address in 24a
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: LI construction to the following.
(Le.auger,rotary,cable,direectpusb,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water SnuPly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy, of this foam within 30 days of
13b.Disinfection typ Amount: t2,at completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department ofEnvironmenta!Quality-Division ofwaterResources Revised 2 22 2016
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