GW1-2022-06255_Well Construction - GW1_20220701

1.W ontractor tion:
14:.WA-TER ZONES,-
Wall . : .• _ ;....,. ...._•..::
well Con tar ame FROM TO DESCRIPTION
ft ft
?A27, .,►A ft. ft
NC well Contractor Certification Number 15:OUZ'E-RQAS'Il\T�,(foc riiniti=raseH Quells)OR 1IlYEE2 Crf_.licable).v:�::'.:,::•:`-:
Morgan Well &Pump, Inc. = FROM TO' DIAMETER THIC=S MATERIAL
Company Name +1 ft. q4 ft 61/81 m sdf11 pvc
16:D� G.OR•T0114G.-•edtliermaZ-a&si:d_--1o0 %
2.Well Construction Permit fir:_ FROM TO DIAMETER THICKNESS •~MATERIAL'
List all applicable well construction arm z L11G Cowgv,State,Variance,etc)• ft ft. m•
aPP• P�
3.Well Use(check well use):
ft ft in.
IV SCREEN,=:: - '•- - � •:. , ..- M
Water SuppIp WeII: FROM TO DIAMETER SLOT SIZ THICKNESSgricultural ai Municipal/Public ft ft in,
Geothermal(I3eating/Cooling Supply) #Rsidential Water Supply(sigle) in•
s�Commercial J Residential Water Supply(shard) ,18.GRODT:; .. .. ,•:IIIi ation FROM TO MA=AL EMPL-4CEMENTME
Non-Water Supply Well: o ft 20 fL bentonite. poured
Monitoring Recovery ft. ft.
Injection-Well
ft ft.
_!Aquifer Recharge I Groundwater Remediation r.
;.79:SgND/G12AVEL
Aquifer Storage and Recovery DSallnityBan-ier FROM TO MAs>urnr• EMPLACEMENTr=01)
Aquifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control ' ft ft.
Geothermal(Closed Loop) MTracer :20.DRILLi1�TGTOG'(aitacIisdditionalsheets�fneces " �''j;:�:•: . is c:.`
Geothermal(FIeating/Cooag Return) -3 Other(explain under#21 Remarks) FROM TO DESCRIPTION(culo,hardness,saiUrockty a giam s ze etc)
Ir. O .ft 10 ft brhkoht
4.Date WeII(S)Completed:(,c _ Well ID# 0. ft ft
VWILell�LoX' n: 0 ft ft •�
ft ft
Facrliry/Owner Name Facility ID4(ifapplicable) R ft.
��reb ooar, M��a> , L Z�co'� ft ft.
/Physical ddress,City,and ZiD ft ft
5..+�C�ei��r °21i-RY:M6RK.0�:is: — - 1:`i•'� :,7''�-_ — _
County Parcel Identification No.(PItq)
Sb"Latitude and longitude in degrees/minutes/seconds or decimal degrees: fMiv+-7n
ss.
(rfwell field,one]at/long is su(ncient) 2 er cafion• +
6.Is(are)the wells) Permanent or OTemporary Signa e f rtified well Contractor De
B purring is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or #@No wr113 15A C 02C.0100 or 15A NC4C 02C,0200 Well Construction Siandcvds and that a
ff this is a repair fill out)mown well construction hiformatfon and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 r emarks 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 yells constmction details. You may also attach additional pages ifnecessary.
drilled: ' 1 QQ/� SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface:_ J b V ( ) 24a For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths ifd fferenI(example-3@2000'and 2@100D construction to the following.
10.Static water level below top of casing:AD (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 Injection Wells: In addition to sending the fors to the address in 24a
12.Well construction method- r 0* LA L above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(ze,auger,rotary,cable,directpusk etc.)
[13h.
R WATER SUPPLY WELLS ONLY- Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 27699-1636
.Yield(gpm) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
Disinfection typ Amount completion of well construction to the county health department of the county
where constructed-
Form Gw-1 North Carolina Department of Il6ironmental Quality-Division of water Resources Revised 2 22 2016