GW1-2022-10728_Well Construction - GW1_20221208

1.Well Contractor Information:
i
Chris Morgan 14.WATER ZONE
FROM TO DESCRIPTION
Well Contractor Name 10 J ft. Q6 ft.
b
3572-A
NC Well Contractor Certification Number 15.OUTER CASING'for miilntasedwells O LIN R` ER if applicable)
Morgan Well & Pump, INC PROM TO DIAMETER' TffiCKNESS MATERIAL
ft. ft. I in.
Company Name (' [� '.16.1NNER CASING OR.TUBING(geotlie,rm.alilosed-lo'o'
3S�� `� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. ft. in.
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) i
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural ni M icipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) g, ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
FROM TO J MA IA TERL EMPLACEMENT ME M METHOD&AOUNT
- Irrigation 0 ft. Zp ft. bentonite poured
Non-Water Supply Well:
_'Monitoring Recovery
Injection Well: ft. ft.
L...e Recharge Aquifer Groundwater Remediation
Q g _,19 SAND/GRAVEL PACK"rf.a'licable
Aquifer Storage and Recovery oSalmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ostormwater Drainage
Aquifer Test @J g
Experimental Technology DSubsidence Control
Tracer 20.'DRILLING.LOG(attack.additional"sheets if necess
Geothermal(Closed Loop) FROM TO DESCRIPTION(color,hardness,soil/rock e, gin size etc.)
Geothermal(Heating/Cooling Return)) Other(explain under#21 Remarks) O ft. qD ft. t
4.Date Well(s)Completed: I���ZZ Well ID# ( in;
ft. ft.
5a.Well Location:
ft. ft.
-Thaw (,owr✓
Facility/Owner Name Facility ID#(if applicable) M1
ZZS Ofd- R.i�oc.�:y� �-al.r►,� � . S1�15 rN� ....�r�
ft. ft.
Physical Address,City,and Zip
21.REMARKS F '
�oWaux
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer lion'
35 GZ Zo N -$D '�33 W -►5-zz
Signature of Certified Well Contractor Date
6.Is(are)the wells) ix!Permanent or Temporary
By signing this form,I hereby certify;that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: []Yes or XI No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
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 multiple wells list all depths if different(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 2S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: rotary above,
to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air13a.Yield(gpm) Method of test: J 1 it 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..
13b.Disinfection type: chlorine Amount: SOL 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 Resouf ces Revised 2-22-2016