GW1-2022-03788_Well Construction - GW1_20220404

TY,uiuv%_%_P1(IJA.LLUL.AAVIV '(-;V ll ((YW^l) I For Internal Use Only: '
I.W C ntr ctorr T�>ca $ n: i
1 •14:,WATER ZONES-.
Well Co. Name FROM TO DESCRIPTION
ft ft-
NC ft f ft t •
Well Contractor Certification Number I,
'15:OII2•ERG�ASING',(ioi•multi=rasedwells)OI2TTNH'R(ifa']lcahle)',:�::?'.::'•.`.:
Morgan Well&Pump, Inc: : FROM I TO' DL,METER. I THICKNESS MATERIAL
Company Name +1 ft R' 61/8/ ! j sdr21 pvc
P Y
3/// /� 16-`INN R C' G OR•TUBII4G:•d6Ofdrmal'cI6s6&1616' :. ;'
2.Well Construction Permit#:_ (O7 0/ FROM TO DIAMETER THICKNESS MATERIAL
MATERIAL'
List all applicable well construction permits'rl.e.UIC,Cautriy State,Variance,etc.) ft. ft in,
3.Well Use(check well use): ft ft. i in.
Water Supply Well: I7_-SCREEN', -
PROM To••: ,.DIAMETER! SLOTsrLE THICKNESS rh•IATERiAL.••
Agricultural MMunicipal/Public fL ft
i Geothermal(Heating/Cooling.Supply) *Residential Water Supply(single) ft ft in.
Industrial Commercial J Residential Water Supply(shared) ----T::• _ _ _:' :-
Im ation FROM TO MATERIAL - EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft
bentonite• poured
Monitoring Recovery ft. ft
Injection Well: '
ft ft
-._Aquifer Recharge DGroundwaterRemediation
Aquifer Storage and Recovery �, ,Salmi Barrier :.�:SAND/GRAVELTACK(If a"lica6li ;:: .:_.`:_'i:'. •.:',•' ::
E—Y Unity FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Q3stormwaterDrainage ft. ft
I Experimental Technology Subsidence Control ft ft'
Geothermal(Closed Loop) Tracer :20,T1RII LZTIG LOG(attacli=additional sl�eetsad necess 7:;: ':=
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cola ha ess,soillrock type,grain size,ere)
D ft 1d:r ft
4.Date Wells)Completed �Z Well ID# 57 ft 30 ft
w
e11Xation: ft O(7 frI (! L xh ft
Faciii-V/Owner Name FacilityID#(ifapplicable) ft ft
7�'9 5" .ff h AIGZ ft r%r--
P Ad�dres4K.?Qp
s, // ft ft
n
IkPM In
KOW
"I'
County Parcel Identification No.(PIIq
5b.Latitude and longitude in degrees/minutes/seconds or decimaI degrees:
(ifwell field,one Mon.-on.-is sufficient) 22.C cation: 01-IDA f�p��&f��FR 'RT U 1
N
• W Sg �
6.Is(are)the well(s)f(Permanent or Oi Temporary Si, PCO2C.O"e'
e ntractor Date,
tin
ebv cer7rfy that the well(s)was(were)constructed in accordance
7.Is this a repair'to an existing well: Dyes or *No with 15A100 or 15A NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair frll out known well construction information and explain the nature ofthe copy ofthis record has beenprovided to the xell owner.
repair under 421 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:_ ' I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (ft)For mult 24a. For All Wells: Submit,this form within 30 days of completion of well
iple welLr list all depths ifdt�erent(example-3@2n00'and 2@I00� construction to the following:
10.Static water level below top of casing: (� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection WeIIs: In additionto'sending the form to the address in 24a
above, also submit one copy of this foim within 30 days of completion of well 1
12.Well construction method: `�'O Y L construction to the following: ,
(t.e,auger,rotary,cable,direct pusb,etc,)
EDisinfectio
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
` - 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test air pressure 24c.For Water SunD1v&Infection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
typ . o&V Amount: 400�to completion of well construction to the county health department of the county
where constructed-
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2 22-2016
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