GW1-2022-09259_Well Construction - GW1_20221003

rrx.-ruj. 1_U1N011cUk 1iU1NE-EcUbw (UW-1) For Internal Use Only.
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1.Well Contractor Information: , Y
i�8d j
_ c •14:.FOATER ZONES
Well Contractor tame FROM TO I DESCRIPTION
ft. ft.
NC Well Contractor Certification Number ft ft
IS:OUP E3teASTNG,(&i rimitviiisea wens)Obi T7tyrT2 rf'a-'licable•,1
Morgan Well&Pump, Inc. FROM TO' DIUVI•TER, THIC 17ESS MATERIAL
Company Name +1 ft 61/8/ in,
sd21 pvc
I 16."DUM CASIIIG OB•TUBING:rkefthefifiz closed-rod" ?.'::. c t
2.Well Construction Permit#: 1 J FROM TO DIAAIXr•FR; TgICICKESS MATERIAL
List all applicable well construcdonpermits'(ia UIC,County State,Partance,etc)• ft ft. 'in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 11-SCREEN'.-.:: ::. .' .- ._
FROM TO DIAMETER!. SLOT SIZE THICKNESS MATERIAL.
E Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Jo
Residential Water Supply(single) ft ft. in.
17ndustna-7l Commercial _i Residential Water Supply(shared) :$ D '• .. _•.,.,;...,.::• -
'Ini ation FROM TO MATERIAL EMPLAtEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonfte poured
[Geothermal
itoring Recovery ft ft
on Well:
ft ft.
fer Recharge KI Groundwater Remediation
er Stora a and Recov ; t.-19:SAND/GRAVEL•PACK ti ii blichble f g ery DSalinityBa rier FROM TO MATERIAL EMPLACEMENT METHOD
fer Test Stormwater Drainage M ft.
imental Technology jlSubsidenceControl ft ft
ermal(Closed Loop) Tracer(Iieating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrocktype in s ze etc)
(� ft Q ft
4.Date Well(s)Completed: /_ram Well ID# P ft 1�10_ f L I SQ/l 0
5 Well Location: ft b ft
a /l'1 tuft 21A A,4, d
Facility/Owner N Facility M# fapplicable) ft ft
y/Cw 3 P/ V/W il t r z .
Physical Address,City,and Zip ft ft.
�] /�1 ' 215aa�nrAuuc .'.<:;:->:-:,•-..:c'' .xs_::::°,'• :., '_f -
Coun Parcel en6fication No.(PIN)
•�•s:;,g Lir;
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/lona is sufficient) 22.Certification:
6.Is(are)the well(s) Yermnnent or OTemporary Si-m eofCertified Well Contractor Date
,,,.��11 By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or No with I5A NC,4C 01C.0100 or]SA NCAC 01C•-0100 We11 Construction Standards and that a
Ifthis is a repay,fiII out known weR cons6•ucSon information Ad emplain the natm•e ofthe copy ofthis record has been provided to the well owner.
repair under#11 remarks section 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 land surface: LLSJ (R-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(emample-3(ar200'and 2Q100D 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.Borehole diameter: 6 (in.) 24b.For Infection Wells: In additionito sending the form to the address in 24a
12.Well construction method: r o"r LJ above, also submit one copy of this four`within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
F
OR WATER SUPPLY WELL( Division of Water Resources,Underground Injection Control Program,
2 { 1636 Mail Service Centel,Raleigh,NC 27699-1636
Yield(gpm) GJtl Method of test air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
/� the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection type: C Ill n P, Amount: q completion of well construction to the ccounty 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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