GW1-2022-03781_Well Construction - GW1_20220404

., •"�ui.,�.vl.ux.�r�a��,11y1`( rcn,l�VtUJ (IrVY-1) 1*orintemal useunly:
1.Well C tractor Information: I
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QU•.•S�.- •14:,F�ATERZONES•:'.
Well Contractor Name z
O DESCRIPTION -
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ftNC Well Contractor Certification NumberMorgan Well&Pump, Inc.Coro an Name ft 61/81 In' sdt21 pvc
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,:So Q �j �f 16.Il�II•M CASIl�IG OR•TOBR ZG.' eotherma1 r1o'sed-lad' :. ''..>•
2.Well Construction Permit#:_ J J ( FROM TO DIAMETER TffiCIMESS MATERIAL
List all applicable well constructionpermits r e.r C,Comity,State,Variance,etc.)• ft. ft. I` in.
3.Well Use(check well use): ft ft- �' in.
Water Supply Well: 17_-SCREEN; t::. .w; •.•_ -'•.:':.:'L::b• ":r.. =r
FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL.
_!Agricultural DMuaicipaLTublic ft ft
6
i Geothermal(Heating/Cooling Supply) R=idential Water Supply(single)
I ft u ,
Industrial/Commercial Residential Water Supply(shared) IS:GROUT::
Irrigation FROM TO MATERIAL' EMP1ACEMENTNMTHOD&.d1 OUNT
Non-Water Supply Well: 0 ft- 20 :M bentonite•I, poured
Monitoring DRecovery. ft ft
Injection Well: ft _ft
_J Aquifer Recharge �CnoundwaterRemediation% ,.-19:SAND/GRAVELP9CK if i"livable - , '•' ;:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL " EMPLACEMENT METHOD '
_'Aquifer Test 13StormwaterDrainage ft ft
!Experimental Technology Subsidence Control , ft ft
i Geothermal(Closed Loop) OTracer :20.DRILLIIVG�OG'(attach'additiorials7aeetsifaeces's"
Geothermal(Heating/Cooling Re in) J Other(explain under#21 Remarks) FROM TO DESCRIPT ON(color,hardness,soillrock type grain sae eta)
6 ft. l� fL �Le: D•�- .
4.Date Well(s)Completed:J ` 2a Well ID# 25, ft sa ft t-b k-)" 'b,v1—
Sa.Well Location: b ft O ft. �0 L-A (
' Ca►`r'c � 1ZvsS ��,kr>t u,,- ja ft a J ft -Cw•'-
Facility/OwnerName Faacili ft ft
1075- }N�Orr-' T1
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ft ft
ft
Physical Address,City,and Zip
ft v C
.L.
County Parcel Identification No.(PIN) I II
5b.Latitude and longitude in den ees/minutes/seconds or decimal degrees- *"
(if well field one latAong is sufficient) 22.Certification:' Act r i I y,1
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6.Is(are)the well(s)oPermanent or E3Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [J No t with ISA NCAC 02C.0100 or ISA NCdC 02C,0200 Well Construction Standards and that a
Ifthis is a repair,Jul out known well construction ififormation and explain the nature ofthe copy ofthii 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 I GW-1 is needed. Indicate TOTAL NUMBER bf wells- construction details. You may also attach additional pages ifnecessary.
drilled:- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ov (ft)
24a. For All Wells: Submit this faun within 30 days of completion of well
For multiple wells list all depths if different(example-3@2 00'and 2@100) construction to the following:
10.Static water level beIow top of casing: Q (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241i.For Infection Wells: 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: `C'0,� LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection'Wells: In addition to sending the form to
Q the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: +r<^-I 4( Amount: u 6Z' completion of well construction to the'county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources Revised 2 22 2016
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