GW1-2022-03192_Well Construction - GW1_20220307

1.,We4'g9ntractor Informati n'd h
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•14:.WATER ZONES,,'. .' i-_',..�:.�`.r':.,. .'.'."....•..i•.
C ct Name FROM I TO DE IP SCRTION
fG I ft.
-A ft ft
NC Well Contractor Certification Number
IS:OUTERCASTNG,(i& ulti=ragedweDs)OItSLn*ER(iflap
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICKNESS MATERIAL
Company Name +1 ft ft 6 1/8/ in' sdr21 pvc
�I�_(„� 16:IlVNIIt Ce1SING ORTIIBIIVG.' eotliermal'cIo'sed lou'
2.Well Construction Permit#: 1(�/[/ FROM To DIAMETER TffiCENESS MATERIAL`
List all applicable well construction permits'(ie, C,Cotaity State,Ymiance,etc.)• ft ft m'
3.Well Use(check well use): ft ft. in.
JJ
ater Supply Well: IT SCREEN'.:>'. .:. _:. .`•�: .. :.:::.::'t'. ::.::- > _' :;.:. =:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipalRublic ft ft'Geothermal(Heating/Cooling Supply) Residential.Water Supply(single) ft ft in.
ndustrial/Commercial J Residential Water Su 1 shoed :,>,.;..__
Supply( ) -.:18:GROUT--'-.." _
Irrigation FROM TO MATERIAL Y EMPLACEMENT METHOD&_AMOUNT
Non-Water Supply Well: o ft- 20 fL bent poured
Monitoring Recovery ft. ft
Injection Well: ft ft.
_J Aquifer Recharge Groundwater Remediation
:.79:SIiND/GRAVEL•PA.CK if a'licatile ....:_. -':;..'• .. ..
Aquifer Storage and Recovery OSalinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(attiicli addiHiirial sheetsjf aeces's-"'�t''�'.""i '
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrack ty e, in size,eta)
�f a.ft 5 �- �
4.Date Well(s)Completedl/ Well ID# ft ft
/ —V--T-- k
SSa.Well Location: 20 ft ft 76
Oft t,
Facility/Owner Name J Facility ID#(if applicable) ft. ft
C_ Z�MT ft ft
ate'P sical Address,Ci ,and Zip ft ft
.
im In
County Parcel Identification No.(PIN)
5 .Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tf���'N
field,
*172
on: n�c,
w Z�?�_ ZL
6.IS(are)the wells)J@Permanent or ©ITemporary tified Well Contractor D
orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: J Xes or �No 02C.0100 or 15A NCAC OZC.OZ00 Well Construction Standen ds and that a
Ifthis is a repair fill out known well construction idformation 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 ifnecessary.
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 ifdifferent(examp e-3(t�'aiand 2@100) construction to the following:
10.Static water level below top of casing: %.Jy (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 Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this Ifoim within 30 days of completion of well
11 Well construction method: r otp LI construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Undergroun d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ZO - Method of test: air pressure 24c.For Water Suonly&Iniection Wells: In addition to sending the form to
/ the address(es) 'above, also submit one copy of this font within 30 days of
13b.Disinfection Amount: IJV� 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 Resources .`` Revised 2-22-2016
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