GW1-2022-09245_Well Construction - GW1_20221003

_yYL+,LI'_,UU1Nb 11{UU'1'1U.N RECORD (GW-1.) JFor Internal Use Only. i I
1.Well Contractor Information: r
�� 14..WATER ZONES r
Wel o Name FROM TO DESCRIPTION
ft ft �
ft ft
NC ell Contractor Certification Number
-15;OU2MR,C4BING,(for mniti_dised wens)OR IIKM(rf a'livable)'.
Morgan Well&Pump, Inc. FROM TO' DIAMETER I THICHMESS MATERIAL
Company Name +1 ft ft 61/81 sdt21 pvc
,1f 2 / IC'DU 12 GOB•TTIBTNG. eotfiermalclosedlori' '':.
2.Well Construction Permit#: HW 2 I -' ain yJ�(D FROM To DInn2ETER THICKNESS MATRRL4,L
List all applicable well conso,uctionpem '(La WC,Cowlty,State,Ymiance,etc} f, & in.
3.Well Use(check well use): Ft. in.
Water Supply Well: 1!SCREEN',: :•:.: :'..:-:.-:.. r,.-::: ::
FROM TO DIAMECER SLOT SIZE+ THICKNESS MATERIAL.
Agricultural �Muaicipal/Public it ft in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft �•
1 Inndustn Commercial J Residential Water Supply(shared) - ..r.-::••:-_.,•_::
E hat ation FROM - TO MATERIAL EMPL_4CEMENT METHOD&AMOIINT
Non-Water Supply Well: 0 fL 20 ft bentonite. poured
Monitoring DRecovery M ft
Injection Well: ft ft
_Aquifer Recharge K GroundwaterRemediation , .
;.79:SAPID/GRAVEL•PAC)S if a"livable :.'':::'r.:•_ .:'. ..:•`-_
'Aquifer Storage and Recovery 0Salinity Barrier FROM T`0 MATRRTdT. Eil7PLACFdl2ENTMETHOn
J Aquifer Test Stormwater Drainage ft ft.
_Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) E3Tracer :20.DRnUNGLOG(attacli:dditidnalsliee6,iffiecegs 7':'. 't %
FROM TO DESCRIPTION(color,hardness,soil/rock ty e,grain size,ett)
Geothermal(Heating/Cooling Retain) J Other(explain under#21 Remarks) 10 � ft � �
rl-
4.Date Well(s)Completed: ��Well 1D# ,,�0 ft fc
55aa.Welll Location:
�
R ft V W 'i • 63• R ,•.
Facility/Owner Name Facility ID4(if applicable) ft ft.ft ft
Physical^Ad�drreesssj,City,and Zip ft ft P.,s ! „^g 1Ur'
�i, �V�+l-/\, Zl:'R�:M:i'RTIR _ - -:i- - _ _ `_-_- .r<`5.�= -n•'1')-;;•:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
& ZI
(tfwwelllffield,one lat/long longitude.
is sufficient) Q 22.Certification•
� c
6.Is(are)the well(s) Permanent or [3Temporary i tureofCertiffedWellContractor 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: 0'Yes or n No wth 15A NCAC 07C:OI00 or 15A NCAC 02C.0200 Well Construction Standards and that a
ythis is a repair fi0 out known well construction Lfiformatio a lain the natw•e of the copy ofthii record has been provided to the well owner.
repair underW21 remarks section or on the backofthisform. 23.Site diagram or additional well details:
8.For GeoprobeMPT 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: ( 65 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths ifdi ferent(example-3@200'mud 2@100) construction to the following.
10.Static water level below top of casing: A) 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.) 24b.For Infection Wells: In addition ito,sending the foffi to the address in 24a
above, also submit one copy of this fog within 30 days of completion of well
12.Well construction method: 'r o"r L` construction to the following
(Le.auger,rotary,cable,direct pusl;etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�7NLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water SunDly&Iniection Wells: 1n addition to sending the form to
J / ` the address(es) 'above, also submit one copy of this form within 30 days of
/�
13b.Disinfection type: l .lc)( t�/ Amount: l9• Z, completion of well construction to the county health department of the county
where constructed I
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016
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