GW1-2022-06175_Well Construction - GW1_20220701

For Internal Use y:
I.Well Contractor Information:
14:.W.TER ZONES :
Well Contractor Nam FROM TO DESCRD:TION
O5-1� D ft IV, ft
ft ft
NC Well Contractor Certification Number
� '15:OU,CER:CASII�TG,(fo"r riiulfi=cased�velLs)ORTTNF'R(if_.licahle)'
Morgan Well&Pump, Inc. : FROM TO' DIAMETER Ts�cI�NEss MATERIAL
Company Name +1 ft i,or7 ft 6 1/8/ in. sd,21 pvc
35q 16 MMR CASING 012•TIIBING' eotherma7 cldsed moo`i -'_' :>
2.Well Construction Permit#:__ FROM TO DIAMETER TMCE2gEss MATEPJA. `
List all applicable well construction permits'r e.VIC,Cowrty,State,Variance,etc-)- it• ft in.
3.Well Use(check well use): ft ft• in.
J-4
ater Supply Well: 1�SCREEN', :I_:. .'� •.=•t_.:: +::::. =',::_(..: :: ;...��. : :::° .
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
OMmicipal/Public ft. ft
eothermal(Heating/Cooliug Supply) i Residential Water Supply(single) ft. ft in.
ndustrial/Commercial ,J Residential Water Supply(shared) -
JAq
i ation FROM TO MATERIAL EMPLACEMENT METHOD&__UNgT
-Water Supply Well: o fL 20 ft. bentanite- poured
onitoring Recovery ft. ft
ction Well:
ft ft
uifer Recharge Groundwater Remediation r.
:.IK SAND/GRAVEL• A:CIC rf ie"tcable
'Aquifer Storage and Recovery rI Salinity B arrier FROM To • MATERIAL •EMPLACEMENT METHOD •.
uifer Test IStormwaterDrainage fL ft
perimental Technology E38ubsidence Control ft ftthermal(Closed Loop) 1ITracer ;20.T)RIGLIlIGS OG'(aitaclisddi[iomi'sI sliLtsjfiiecessthermal eating Coolin Retain) FROM TO DESCRIPTION(color,hardness,soil/rock e,grain size,ete.)
(H g/ g ) i Other(explain under#21 Remarks) a G I
4.Date Well(s)Completed: Well ID# ud ft' 70 ft- few
H. ray C
5a.Well Location: & fL Yf 5 ft.
�J Cj S f` d ft. Crime' vf .
Facility/Owner
Name Facility ID#(if applicable) fL ft :
O V fL ft ua p
s !a } .i
Physical Address,City,and Zip at; ,OPO C ON
ft ft
Spa oq6
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35 (# ?15"7 -N -8a, 1fr513 W
6.Is(are)the wells) 'Permanent or OTemporary Signature of Certified Well CagFactor Date
� By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an ex%sfing well: Q Yes or.;?go with ISANCAC 02C.0100 or ISA NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair fill out known weII consLvction information and explain the natut•e 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 CIosed-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 conshnction details. You may also attach additional pages ifnecessary
drilled: fl 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 a!1 depths if different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of easing: 6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casitrg,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Il.BorehoIe diameter: 6 (in.) 24b.For Injection Weill': In addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: c o �U✓ . construction to the following:
(ie.auger,rotary,cable,directpusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELL5�9NLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suuuly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 0 2. 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 WaterResources - Revised 2 22 2016