GW1-2022-03783_Well Construction - GW1_20220404

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1.WeII�ctor Inform
•14:WATERZONEB:'. - ':•: ;' :I.s:........., .. .•' •
r
Well Confta= ame FROM TO I DESCRIPTION
NC Well Contractor Certification Number
'15:OUTER:CASING,(foc multi-r2sea•wells)OR i2iF,2(if'a Ucable
Morgan Well&Pump, Inc. FROM TO' DIAMETER? I TMCEM-SS MATF.RTAS•
Com an Name +1 ft ft a 1/81 !n' 'sdt21 pvc
p y ICINNER CASING OR-TQBII�G''eottiermal cIo'sed rod`
1Permit6 / �/ FROM TO DIAMETER: THICKNESS ::•.MATERIAL
Z.Well Construction #:
List all applicable well construcdonpermits :.e.&7C,Coialty,State,Variance,eta)• ft ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.-SCREEN'.:,:..r;. i=:. .`^r'•.6•`_..': ?::.• r;..> -:.;::i�.: :;.. .:::
FROM TO DIAMIM7JU SLOT SIZE THICKNESS MATERIAL.
Agricultural CIMunicipal/Public ft fL
i Geothermal(Heating/Cooling Supply) i1Residential Water Supply(single) ft ft in.
I Industrial/Commercial J Residential Water Supply(shared) .-GROUT-.`.
. -
lGeothermal
tion FROM TO MATERIAL - EMPLACEMENTNJ=OD&4MOUNT
ater Supply Well: o ft- 20 ft bentonite•', poured
oring Recovery ft. ft
n Well:
ft ft '
r Recharge 1 0Groundwater Remediation
r Storage and Recovery i 5alinj Bawer :.�:SZiND/GRAVEL PACK d a'llcable ':;: .:i' •:..:•: %. '::
t3' FROM TO MATERIAL - FrViPLACEMENTMETHOD
r Test DstormwaterDrainage ft ft
i
mental Technology OSubsidence Control ft ft
rmal(Closed Loop) EITracer 20.DRILLING.LOG(.ktti&H'dditioual s'lieets,if aecess"')° :•: .:
rmal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRI TIo (oat r,hardness,saiUrock type,grain size,eta) '
/y ft 1'a ft lY
4.Date Wells)Completed ! Well M# ft 5 ft
Sa tW cation: ft 5 ft
J� 5 ft o ft
Facility/Owner Name Facility ID#(if applicable) ?a ft 1 C o ft
�fi✓ l !�G// rY/ 1 d ft ft
P caul Address,� ,and Zip ft ft
�y'J✓�'�'� •'. /�f 3 '21:'IiFmrenuc= - -:,- W_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: wo
(if well field,one lat/long is sufficient) ` 1- a
22.Certification: i, ,,Q)bm
N �6. 31/0 W 3 Z ,
6.Is(are)the well(s) Permanent or QlTemporaly S' Certified Well Contractor I, D e
y sio i this form,I hereby term that the.well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O1 Yes or V No with 15 NCAC 02C.0100 or 1SA NCAC 02C-.0200 Well Const,action Standards and that a
If this is a re f:11 out known well construction information and explain the nafw a of the copy ofthis record has beta:provided to the well owner.
repair under 421 remarks section or on the back of thisform. 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'of wells construction details. You may also attach additional pages if necessary.
drilled:__' t1 SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: (ft-) 24a. For All Wells: Submit this form within 30 day§ of completion of well
For multiple wells list all depths ff&fferent(example-3(200'and 2Q100D construction to the following:
10.Static water level below top of casing: 4 (ft-) Division of Water Resources,Information Processing.Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
.11.Borehole diameter: 6 (in.) 24b.For Iniection FVells: -In addition to sending the form to the address in 24a
12.Well construction method Y 0above, also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,eta)
IT construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,?Raleigh,NC 27699-1636
13a.Yield air ressure
(gpm) Method of test P 24c.�For Water Supply&Injection Wells: In addition to sending the form to
�t/�• the address(es) 'above, also submit one',copy of this form within 30 days of
13b.Disinfection typ V/ h Amount: completion of well construction to the county health department of the county
where constructed. i
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Form OW-1 North Carolina Department of136iromnental Quality-Division of Water Resources f i Revised 2-22 2016
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