GW1-2022-10227_Well Construction - GW1_20221111

1.W ontractor)nf mation: L
14:.wATER ZONES
Well Con for ame FROM TO I DESCRIPTION
� ft ft
-i (` fC ft.
NC Well Contractor Certi f cation Nmbet k
OUTER-,CASING,(foc multi�isedlfveilc)012I.II�T1><L2 rf'_.IIcahia.r,;•:;;..:' .'.;
Morgan Well&Pump,Inc. FROM TO' DIAMETER` THICKNESS MATERIAL
Company Name +1 ft. 61/1 sdr21 pvc
t r Id II R CASING OE•TIIBII G— eotlierma7 closed-lou'
2.Well Construction Permit#: \�[Y�, t FROM TO DIAME-ER I THICKNESS I MATERIAL
List all applicable well constructfonpermits'(Le.UIG Corotiv,State,Variance,eta)- ft ft. I in.
3.Well Use(check well use): ft m
Water Supply Well: 17:SCREEN'„
FROM I TO `. DIAMETER••11 SLOT SIZE I TETCKKESS MATERIAL.,•
Agricult i al CDMunicipal/Public ft it. in.
I Geothermal(Heating/Cooling Supply) *Residential Water Supply(single)
_ ft fL �•
ustn ommerciai i Residential Water Supply(shared) ::`lK GRODT: :_•r• -
•.kigation FROM I TO I MATERIAL L Eh4P =CEMENTMETHOD&AMO=
[Aquifer
ter Supply Well: o ft 20 ft- benionite poured
ring Recovery ft ft
r RechargeGroundwater Remediationft Storage and Recdv ery DSalinityBarber FROM I OMATERIAL OD TestStormwater Drainage ft ftmental Technology Subsidence Control ft ftmal(Closed Loop) Q1Tracermal(Heating/Cooling Return) _i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype6 grain size,ete)
o •& 15 RA AV:6
4.Date Well(S)Completed-: ZZ Well ID# i5. ft- yUU
Sa Well Location:
5it. S ft j;L
• �aw�llrtZ �� •v�.�' �e� r` Cx7� i�t�
Facility/Owner Name Facility ID#(if applicable) ft ft
1`CA�5 e_�o i e7 ft ft
Ph sicalAddress,City,and Zip f. t yy ft ft
SA
County PaicelIdentificitionNo.(PIN)
5b.Latitude and lone tude in degrees/minutes/seconds or decimal degrees:
(dwell field,one latilong is sufficient) 2 ration: 11
6.Is(are)the well(s) Permanent or OTemporary Siva f ' ed Well Contractor Date
B fining is form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or *No wuh 15.4 C 02C.0100 or I5A NCAC 02C,0200 Well Construction Standards and that a
Ifthis is a repair fill out)mown weB construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 4121 remarks section or on the back of this form
• 23.Site diagram or additional well details:
8.For Geoprob'e/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 I 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: 3CO A) 24a. For All Wells: Submit this fi:i within 30 days of completion of well
For multiple wells list all depths ifdiierent(armnpleB@.200'and 2@100D construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,!Information Processing Unit,
Ifwarer level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method- � �L` above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpush,eta) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 2 7699-1 63 6
i
13a.Yield(gpm) _ Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit onelcopy of this form within 30 days of
13b.Disinfection typ Amount b7i completion of well construction to the county health deparbnent of the county
where constructed- i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016