GW1-2022-03191_Well Construction - GW1_20220307

1.Well Or
actor I lion:
14:.WATER ZONES
Well Contra or ame FROM TO I DESCRIPTION
3 ft "L
1-T ft ft
NC Weil Contractor Certification Number
15;OUTER:CASING,(foc multi-ras6a we11s)oR-lmyEA if a--licable)'
Morgan Well &Pump, Inc. FROM I V I DIAMETER I THICKNESS MATERTsr.
Company Name
+1 ft ft 61/8/ in' sd121 pvc
,
16..INNER C- G OR•TIIBIIVG.' eotliermal cIo'sed Nod'
2.Well Construction Permit#: FROM To DIAMETER THICIams MATERIAL
List all applicable well construction perm' c e.UIC,Cowuv State,Parlance,etc.)- fL ft. m.
3.Well Use(check well use): fL ft in.
JIGeothermal
ater Supply Well: iz:SCREEN'.::. : ':;. .`w.. ..• .::.:;:.•;.: .;.:�; >•i.,: ,.-n.;.. .:: ° .=.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
Agri
cultural DMunicipal/Public ft tft
(Heating/Cooling Supply) aResidential Water Supply(single) ft
ndustrial/Commercial i Residential Water Supply(shared)
;18:GROUT•.
Im ation I FROM TO I MATERIAL EMPL.4CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite• poured
Monitoring DRecovery ft ft.
Injection Well: ft ft.
IiGeothermal
Aquifer Recharge r—lGroundwaterRemediation19:SAND/GRAVEL PACK if a"licatile Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAI EMPLACEMENT METHOD
Aquifer Test DStormwater DrainageftExperimental Technology Subsidence Control ft ftGeothermal(ClosedLoop) OTracer
(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,saillrock type,grain size,eta)
V ft j D ft
4.Date Well(s)Complete ell ID# \0 ft v ft
a.Well Location: 3a ft ft
` ft ft
Facility/Own er Nam Facility M#(if plicable) ft ft
n '►a a�` �n .,
- .
1 ft ft
Alrysicsi ss,City,and Zip ft- - ft - - MAR-':.:• .^`027 _
(/��+ l l7S G..�✓ c21i'R�'MARKC' `:," _ :`` '.':.:'..
(1Vie.-.}<rfr�. .:•... . .
tYi1.Y:iM.LI{.=i�
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 tificatio
'�'sC507 N OU w �Z Z
6.Is(are)the well(s)*Permanent or [ (Temporary Sign Certified Well Contractor Date
B si g th form,I hereby cer2zfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: UJ Yes or ApNo it IS AC 01C.0100 or 15A NCAC 01C..0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 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 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
17
9.Total well depth below land surface: V (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 2200'and 2@100) construction to the following:
10.Static water level below top of casing: D (ft) Division of Water Resources,Information Processing Unit,
If water 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 foam to the address in 24a
above, also submit one copy of this'form within 30 days of completion of well
12.Well construction method: �� �LI
auger,rot construction to the following:
(Le.au g rotary,cable,direct pusly etc.)
Division of Water Resources,U lderground Injection Control Program,
FOR WATER SUPPL/X.�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 2a - Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
��„l�L the address(es) 'above, also submit gone copy of this form within 30 days of
13b.Disinfection typ5%1 Amount: completion of well construction to the county health department of the county
where constructed. �,
Form GW-1 North Carolina Departnent of Environmental Quality-Division of Water Resources !` Revised 2-22 2016
I