GW1-2022-10165_Well Construction - GW1_20221110

1.W otthacforinf ation:
14:.WATER ZONES
Well Contrarloryerne FROM TO DESCRIPTION
Z-= —A (RECEIVEDfL
NC Well Contactor Cetti(ication Number
NO V 1 U 2022 FR;OUTER••G�T.0' ,(fo`rmniti=rasedweDs)ORLCMIMS ' MATERIAL
Morgan Well&Pump;Inc. FROM To' nIAMETER s�criss nzATFRIA>
+1 ft deft 61/8/ sdf21 pvc
Company Name intor#'►atien Pras;aeeilep UM[ .. ,, :,:...:,:;•,.. ..:. .
��yy��,,//,,�,,� �� It%�IalEI2 C:4SWG OZt•TI7BING. eotliecinal•rlo'sed-lob
2.Well Constru flon Permit#l: 2.62o FROM TO DTeturF rt R THICKNESS MATERIAL w
List all applicable well constt uctfon permits(t a UIC,Corativ Stale,Variance,etc)- ft. ft• I in.
3.•Well Use(checkwell use): ft fL in.
11-SCRIMN',;•:.: �� ..-• _:_t -_ '. : :
Water Supply Well: I. PROM TO DIAMET SLOTSrZS .YTHiCK=s M,4,TERIAL
Agricultural 0MumicipaYPublic ft ft in.
!Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft
I Commercial J Residential Water Supply(shared) GROUT::. _ _fN
tion FROM TO MATERIAL I zD"31 CEMRWMETHOD&AMo=
ater Supply Well: o fL 20 fL bentonfte. poured
oring. ORecovery ft ft
n.W-e11:
ft. ft.
er RechargeGroundwater Remediatioal.19:SgND/GRAVEL'P9 CK ifa'•licable -..r Storage and Rec&Very SalinityBanter FROM TO MATERIAL ENPLACFZEENTMETHOD
r Test OStormwater Drainage ft.mental Technology OSubsidence Control ft ftrmal(Closed Loop) �Tracer ;20DRICLING 1 OG-(attacli'additi6iig Y9etsjiae-cess!.Y 7:rmal(FIeating/CoolingRealm) Other(explain under#21 Remarks) FRomI ro DESCRIPTION ealor,Hardness,saiUrocktype grainsip ek)
. h ft b ft-
4.Date Well(s)Completed:lb ' Well ID#} b ft O ft.
Sa.Well Location: rr 36 ff- b fL
SO fL., b f`
Facility/OaerName Facility ID#(ifapplicable) ft ft
ft ft •
Physical Address,City,and Zip R ft-
county Parcel Identification No.(PIIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2 ration:
N
6.Is(are)the well(s)vermanent or OTemporary Sigma LTHArtilled Well Contractor Date
B p vng is form,I hereby certz•fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or.*No wuh ISA C 02C.0100 or ISA NCAC 02C:0200 Well Constriction Standmde and that a
If this is a repair,fill out known well construction information and eiplain the nature of the copy ofth6 record has been provided to the well owner.
repair under 421 remariz section or on the back of thisform
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 ifnecessary.
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 multt'ple wells&t all depths ifdrferent(example-3 200'and 2@100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwata level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
~12.Well construction method: 0 L� above,also submit one copy of this form within 30 days of completion of well
(ie.auger;rotary,cable,duectpush,etc)
construction to the following:
LFORATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
eld(gpm) \ J Method of test: air pressure 24c.For Water Supply&IniectionWells: In addition to sending the form to
the addresses) 'above, also submit one!copy of this fog witbin 30 days of
sinfection typ Amount 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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