GW1-2022-03777_Well Construction - GW1_20220404

rr.v�uty<,V1�fJ A11U 1.J.a Vl�!tCt'�(�VtC,U ((.rW-1) I For Internal Use Only: + I
I.Well Contractor Information:
1�41•tIS }V\y��lA✓1 •I4:.WATER ZONES;'. 'S.�t• .
Well Contractor Name FROM TO jj DESCRIPTION
3572-A M ft
ft ft I � •
NC Well Contractor Certification Nmnbet
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15:OD2ER:CASIN191(fo"r multi=rased wells)O2 LIlyFR(if'a"licahle) ::' .`.d
Morgan Well&Pump, Inc. _ FROM TOO'' DIAUMTERI TEICMMS
an
P Y MAn HRTA7.
Corn Name +1 ft 414 ft- 6 i/8/ 1 jin• sd,21 pvc
f 16..-DMR CASING OI2•TIIB]NG eotherma7 closed loo"r r '•>
2.Well Construction Permit#: c7 � FROM To DMMETERI THICKNESS MATERIAL
List all applicable well construction permits'(te.LUC,County,State,Variance,etc.)• ft ft. j 9n.
3.Well Use(check well use): ft ft in.
Water Supply Well: L 17.-SCREF.IT'.:,:.:
FROM TO DIAMETER;-SLOT SrZE TRTCKNFSS I MATERIAL
Agricultural _i imicipal/Public ft. it. in.i
I Geothermal(Heating/Cooling Supply) JoResideatial Water Supply(single) ft : ft in.I
I Industrial/Commercial Residential Water Supply(shared) :ISiGZ20DT:: _:,}:°.:•:_=- -
I Im ation FROM TO I MATERIAL Y ENTIACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite• poured
•Monitoring Recovery ft. ft
Injection Well: ,
Aquifer•Recharge OCn ft ft
oundwaterRemediation
Aquifer Storage and Recovery DSalini Barrier :
tY FROM TO • MATERIAL MWLACEl4IENTAMEOn
i Aquifer Test �IStormwater Drainage ft &
I Experimental Technology OISubsidence Control _ ft ft
Geothermal(Closed Loop) DTracer :20.TlRMUNG.LOG'(attaeh'idditiag slieedifiieces's-7': =.
Geothermal(Heating/Cooling Return) Other-(explain under#21 Remarks) FROM ' To DESCRIPTION(color,hardaess,soil rock type grain s ze ete)
d �S �t C�•
4.Date WeH(S)Completed: -J�' Well ID# «i ftYL'v✓i GtG
Sa.Well Location:
ft p /�O•Ll �i I�CY� J�'. L-0�. ft
Facility/ wner Name /1 Facilit99y ID#(if applicable) ft t f
SS 3 ��o�� 0.� .Iri14 L�ei+�Kef O/S• ft ft. I
Physical Address,City,and Zip ft ft i
T�GL.r41r1 �'I�• �`1E� :215•u�•mrenuc�: ':�;:' `:,� _� '< _ -_ - _
County Parcel Identification No.(PIN
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^
(if well field,one laUlong is sufficient) mot, 22.C do
6.Is(are)the wells) rmanent or r3Temporary Signatur ofCe ed Well Contactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Mell Construction Standards and that a
Ifihis is a re fill out known well construction ixformation and explain the nature of he,
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�'f >�`�Y ee .ssary.
drilled:_ I.
SUBMITTAL INSTRUCTIONS ��u
9.Total well depth below land surface: 6d'
(ft) 24a.For All Wells: Submit this forit�hin 30`d `UP completion of well
For multiple wells list all depths if different(example--33(,200'and 2Q100) constriction to the following i
Z
10.Static water level below top of casing: © (ft.) Division of Water Resources I - t,
.Ifwater level is above casino use"+" 1617 Mail Servic� 617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In additiori'to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following: i
LFOR WATER SUPPLY WELLS ONLY: v Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) Method of test: air pressure 24c.Far Water Sunuly&Iniection W! ells: In addition to sending the form to
ifi the addresses) 'above, also submit one copy of this form within 30 days of
Disinfection e: l W Amount: (d
type: 07 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 Revised2-22-2016
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