GW1-2022-10735_Well Construction - GW1_20221208

1.Well C�o)ntractor Informatiob:
�a�1 `� •14:.WATERZONFS;'.
FROM TO •DESCRIPTION
Tel on torName ft ft
fL
NC ell Contractor Certification Number •15;OgT�•1g,QAS�T�,({n`rmnlfi=rasedwells)ORIM-ER(if'a"iicable)=;•:::'..:: '•`•=
Morgan Well &Pump, Inc. FROM xO DIAMETER TSIt `lEss MATTAT.
+1 ft. ft- 61/8/ In. sdr21 pvc
Company Name 1 I(I1�dER C9�SSI�TG 012•TIIBIIVG.'"e itfiermz_a close
d-oo'
1 FROM To DIAMETER TMCIMFSS J:MATERIAL
2.Well Construction Permit: fL. ft
List all applicable well constr uction permits'(r.e.lllC,Coatty,State,Variance,eir-)'
ft ft in.
3.Well Use(check well use): :. , ..-•_: _ -•,• • •: : _
17_-SCREEN',���..�:�=:�. .'•-,•.•'•.:•.:::_�.�:•s:..•:�:-:'.::.,,.:...:....:-.--;• •n
Water Supply Well: FROM I To DIANIErER SLOT SrzE TxlcloeEss tvrATERw .
Agricultural Municival/Public ft ft in.
Geothermal(Beating/Cooling'Supply) tesidential Water Supply{single) ft ft in.
Tndustria]/Commercial !Residential Water Supply(shared) __: :. ,:.•:: :t•::' :- _ .
Trrinati0n FROM TO MATERIAL EMPLACEMENT METHOD&4MOUNT
Non-Water Supply Well: 0 ft 20 fL bentonite• poured
Monitoring DRecovery ft ft
Injection Well: ft ft
_!Aquifer Recharge []GroundwaterRemediation
-19:SkND/GRAVEL'PACK rf a'liraBle ":.:>.•'::'.,:: '
'Aquifer Storage and Recovery Salinity Bawer FROM TO MATERIAL EMPLACEtriENT METHOD
Aquifer Test Stormwater Drainage ft ft
_Experimental Technology Subsidence Control M ft
Geothermal(Closed Loop) E3Tracer :2D:DRILLft�'GIOG'(attach'sdditiorislsheetsifaeces "7'' =.1 r>
ro
TO DESCRIPTION(color,hardn ,sail/mekt p_e,grain size,etc)
RGeothermal(Heating/Cooling Retum) OOther(explain under#21 Remarks)4_Date Wells)Completed: �+WellID# �O r� l
5.9-WeIlLrocaiion: / �fc ft ro%1OCK
13
ft fL
Faciti j/Owner Name Facility ID#(ifapplicable)
IJ G Cc-�-� ft ft
Physical Address,City,an p ft ft • } Ya
I °y1gRFM6RTtA=' - ':j j �_' ra:_ - ` -�'.,'a'`.��i.':t.n�:.c:;= _- _ •
County ParcelIdentificationNo.(PIN) O e) 77
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longissssufficient) 22.Certlfrr2tion: l{1i�;�;£- 1` � Ji rr"+ r/
Sq
6.Is(are)the well(s) Permanent or UTemporary S' e of Certified Well Contractor Date
By signing this form,1 herebv cettfy that the welZ(s)was(were)constructed in accordance
7.Is this a repair to an existing well: r!Yes or Po with 15A NCAC 020.0100 or 15ANCAC 02C.0200 1•Yell Construction Standards and that a
Ifihis is a t•epair f:ll out known well consLuction information and es,I - fhe nature of the copy ofthis record has beets provided to the well owner.
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 land surface: 753 C) UL) 24a.For All Wells: Submit this form within 30 day8 of completion of well
For multiple wells list all depths ifdiierent(example-3@2 0'and 2@J00) construction to the following:
10.Static water level below top of casing: 6 A) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casing,use"+" --1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
% f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 10 LI construction to the following:
(Le.auger,rotary,cable,direct pmb,etc.)
Division of Water Resources,Underground Trajection Control Program, _
FOR WATER SUPPLY WELLS,ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a Yield(gpm) Method of test air pressure 24c.For Water Suunly&Iniection'Wells: In addition to sending the form to
2 the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type• Amount: �J completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department ofEavironmental Quality-Division of WaterResoumes Revised 2 22 2016