GW1-2022-10825_Well Construction - GW1_20221209

WELL CONSTRUCT16N RECORD (GW-1 Pot Internal Use Only: '
I.Well Contractor Info tion: e
•lA:.WATER ZONES•:'.
Well Co rName FROM TO DESCRIPTION
ft ft
NC Well Contractor Certification Numbet
'15:OUTFiR,C�ASIIIG,(foi•mnlfi=eased wells)012I�(rf a'lic?ble)'-1:�::'.:.: •. .-
Morgan Well &Pump, Inc. FROM ER TMICI=s MATERIAL
+1 ti sdr21 pvc
in
Company Name
1tLlxR C6SING O&•TIISII�G:' ea n'serL-Iod'• ''•:..'''• ' '�''••''•
2.Well ConStrncdonPermit4: �� FROM TO D1 ME THICKNESS ... MATERIAL
List all applicable well contraction permits'(ie.UIC,Cow.,State,Ymiance,air-)- �- ti in.3.Well Use(check well use): ft ft
WaterSn i Well: . 17."SCREEN'.��:: _ •, _ •.. . . ,:- ..-•= ..i;. . '.•..•Supply FROM TO „DumErzR :sT o r srzE :YTHrCKMS MATERIAL.
Agricultural MMunicipal/Public ft ft �•
Geothermal(Iieating/CooIing Supply) Residential Water Supply{single) ft ft
I Tndusiria]/Commercial I Residential Water Supply(shared) - :. i.-.:•.-- "`rri ation FROM TO MATERIAL EMPLACEWMUMETHOD&AMOIINT
Non-Water SuppIy Well: a ft. 20 ft bentanite, poured
t Monitoring DRecovery ft. ft
Injection Well: ft ft
-
Aquifer Aquifer Recharge K3GroundwaterRemediation
:19:SiINDIMUVELTA,=(If a Puckbl8 ,.C.•.:N ':.` :.D
Aquifer Storage and Recovery Di SalinityBamer FROM TO MATF.RTdT. EMPLACFdIlENTMETHOD
_`Aquifer Test OStormwater Drainage ti ft
Experimental Technology Subsidence Control ft ft,
Geothermal(Closed Loop) OITracer :20.DRMJM4G.TOG'(attacliadditib'Jiga etsaaeces " 7: i .'r'•': '::`_`l:
I Geothermal(Heating/Cooliag Return) J 0ther(explain under##21 Remarks) FROM TO DESCRIPTION(cola,hardness,soillrackt9pe d ;n s u etc)
ft ft �Ck7 /r
4.Date Well(s)Completed— ` ell 1D# 11 e7 � �I�� �/�
Sa.Well Location: �^ he49�
ft lutes)
FaMlity/Owner Name Facility JD4(Haapplicable)� �?
Physical Address,City,and ZJV ft ft S a s V
County Parcel Identification No.(PIN)
Imv�rr:;,;ssrl Pros�N�, r .
Sb.Latitude and longitude.in degrees/minutes/seconds or decimal degrees: r<t A ram•- 0G
ffi `
(ifwell field,one lat/long is sufficient) 22.Certifi ' n' v re u
. dqzal -N �l.��yl'o W IA' 7-
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
77777�6��6 By signing Zhu form,1 hereby certffy that the wells)was(were)consn ucted in accordance
7.Is this a repair to an existing well: E'Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C,0200 Weff Construction Standards and that a
iftVs is a repay,fiII out]mown weB cons6ucfion iriformaifan explain the nature ofthe copy ofthfs record Fiar been provided so the well owmer.
repair under if21 remarks section or on the back of this form
23.Site diagram or additional-well details:
S.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 NUNMER'of wells construction details. You may also attach additional pages if necessary.
drilled. - SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: 26 o (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi#erent(example-3@200'and 2@100D construction to the following.
10.Static water level below top of casing: �O (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casbra use"+" 1617 Mail Service Center,'Raleigh,NC 2,7699-16I7
' I
11.Borehole diameter: 6 (in.) 24b.For Iniection WeIls: 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: (r` . construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY MLLS,ONLY: 1636 hl2ff Service Center,Raleigh,NC 27699-1636
13a Yield(gpm)a�lJ Method of test: air pressure 24c.For Water SuuuIy&Injection Wells: In addition to sending the form to
/� A' the address(es) 'above, also submit one 'copy of this form within 30 days of
13b.Disinfection type: C 1� /��(f Amount: � completion of well construction to the county health department of the county
where constructed_ I
i
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources I I Revised 2 22 2016