GW1-2022-10235_Well Construction - GW1_20221111

1.WI.Contractor -rnation:
-14:.WA'TERZONES
Well Co for erne FROM TO I DESCRIPTION
A ft ft.
NC Well Contractor Cert*cation Number
11ROO N ( liAble)'
Morgan Well&Pump;Inc. T Sa
MATERUAL
Company Name +1 ft. ft 61/D/ in. sd,21 pvc
l..�V V�/`V �4J 16.71 R CASII�TG OI2•TIIBING:' eotfiermal closed loo`: ' ";' %
2.Well Construction PermitV: _L FROM TO DIAMETER? TIICFONESS •:~ MATERIAL.~
List all applicable weR construction permits'(te,V7C,Comity,State,Variance,etc)• $ ft. in.
3.Well Use(check well use): ft. ft m
Water SnppIp Well: . IVSCREEN', _:.: - .`_ - ::::a:. - ;,,:',:'c:'. r,.-�:;•: •:: '
FROM TO •-- DIAMETER i SLOT SIZE ..TRTc7c ss MATERIAL.
AgriculturalCl Municipal/Public ft ft in. i
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft �•
I Industn Commercial -i Residential Water Supply(shared) ::78:GROUT•::.... .. _ __.,•,.._.:..<=. X. - -
[hri ation FROM TO MATERIAL EDP •CEMENT METHOD&AMOUNT
rnater Supply Well: o ft. 20 ft bentonite poured
ring Recovery M ft
___L
.WeII:
Recharge �CnoundwaterRemediation ft ft
19:SgND/GRAVEL'PA:CK ff a`iica6re
Storage andRecc'very MSalinityBamer FROM TO MATERIAL LY2LAI3MENTM=OD
Test IStormwater Drainage ft•ental Technology Subsidence Control ft ftmal(Closed Loop) DTracer ')' :•=smal(Iieating/CoolingRcturn) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain sip,eta)
r. — V.ft O ft ift­
4.Date Well(s)Completed:lobslL Well ID# I O ft 2Z
ft IV
ft ft
--`S\a��.Well Location:
20
ftU ft '
Facility/Owner Name Facility ID#(ifapplicable) ft• ft t
ft ft. ()
Physical Address,City, Zip ..,�Q61n ft• fL
L� lE.'`i7,VRI '
W
1 _ _ �+rfii
County Parcel Identification No.(PIN) IJY �2f—�(
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient)
Acc'' G�r 2 er ration:
(p •N'i 15P_�(�b. l W (D
6.Is(are)the well(s) ermanent or OTemporary Signa f rtified Well Contractor Date
B o ing it form,I hereby certify thet the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or-*Nc wTzh ISA C 02C_0100 or 15A NCAC 02C.0200 mell Construction Standards and that a
Ifthis is a repair,fig out known well cant ucSon information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back 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 I GW-I 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: 'tV (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths if different(exmnple-3 a 00'mmid 2Q100) construction to the following.
10.Static water level below top of casing: V (ft) Division of Water Resources;Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: 'In addition to sending the foam to the address in 24a
12.Well construction method: O L� above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(ie.auger,rotary,cable,directpush,eta)
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) e� Method of test air pressure 24c.For Water SuD'oly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one!copy of this form within 30 days of
13b.Disinfection typCJA=6 Amount: 10
D completion of well construction to the county health department of the county
where construtted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 72 2016