GW1-2022-07330_Well Construction - GW1_20220809

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1.Well Contractor Information_
cce+j C14uSe •14:.WATERZONES ; :'t' .�:. :r`J.
FROM DESCRIPTrON
Well Contractor Name R R
R ft
NC Well Contactor Certification Number
15;OUTER'aAMG,(fnr multi=&4edwells O_
Morgan Well&Pump, Inc. FROM TO. DL4METER' T8IQff4E55 MATRRTd•T•
Company Name ^ +1 ft ft 6 ilti/ ? in, sdt21 pvc
16'•IIiIQERC:4SITTGOR•TOBING: •eother`mat�cio'sedlo6' '"`'• '�•_�
2.Well Construction Permit#: , FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we➢constructonpermfu'(te WQ,,CowiN S=4 Variance,eta} R ft in.
3.Well Use(check well use):
R fL m
Water Supply Weil: 17 SCRffiQ'.: ._•=_ _ ::r: -: ;..;-,::�r:�• ;.:. .,:.:
FROM TO DIAMETER~: SLOT SIZE Y THICKMS I MATERIAL.
1 Agricultural QMunicipalRublic it ft in.
i
Geothermal(Heating/Cooling Supply)• EkResideniiO Water Supply(ogle) ft ft in.j
I Industrial/Commercial DResideatial Water Supply(shared)
::�8:GROUT•. .
•.Irrigation FROM TO - MATERL4L: EMPLSCEMFNTMETHOD&AMOIINT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft ft
Injection Well:
ft R
Aqui7*Recharge J Groundwater Remediation
'Aquifer St
_ orage and Recovery OSalinity Eanier 'FROM /GRTO PACT I 16ATERIAL e EMPLACEMENT it 03D
Aquifer Test OStormwaterDrainage ft ft
I Experimental Technology OSubsidence Control ft R
Geothermal(Closed Loop) Tracer :20.-MRIL7M-?GLOG'(attact�addition'slTNet_gjfneces's`7'.a'^:`:=.t
I Geothermal(Heating/Cooling Retum) J Other(explain under#21 ) FROM TO DESCRIP ON(color hardness,sa l/rock type,enze,rni si eta)
ft U R
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4.Date Well(s)Completed: Well ID# D• ft d ft O
Sa ell oration: f J ft ft O
5k o c ft mc
R G
Facility/Owner Name Facili M#(ifapplicable) ft ft
�� �; ac ft ft AUG 0" J .2022
Phys' ddress,City,and Zip ^ , ft ft
O 7.7
County Parcel Identification No.(PlJ\D
5b.Latitude and longitude in desaees/minutes/seconds or decimal degrees:
ffl,field on la�no s sufficient) ' 22.Certification: r7
6.Is(are)the well(s) Permanent or [3Temporary Sim,tore.of Certified Well Contractor Datevv�v°��`` By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M`Yes or'4I No with 15A NCAC 02C.0100 or 15R NCAC 02C.0200 Mell Consbuction&mndards and that a
If this is a repair,fill out known well consb•irciion information and explain the natw•e of the copy of this record has been provided to the well owner.
repair under 421 remark 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 if necessary.
dulled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells&1 all depths ifdifferent(example-3(Q200' )(Q100D construction to the following.
10.Static water level below top of casing:_ (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.) 24b.For Injection Wells: In addition'to sending the fomr to the address in 24a
I2.Well construction method construction to the following:
r L� above,also submit one copy of this fomi within 30 days of completion of well
12auge,rotary,
.Well
cable,direetpush,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY.5.TLLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test; air pressure 24c.For Water SnDuly&Inieefion Wells: In addition to sending the form to
_j o�i ,C�2• the address(es) 'above, also submit one copy of this fog within 30 days of
I3b.Disinfection type:�CcU01Gg— Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources - Revised 2 22 2016
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