GW1-2022-07368_Well Construction - GW1_20220808

1.Well Contractor Information: I ,,
YAQ y •FROMATER ZOONFS DFSCRSPTSON r .
Well Contractor Name
3577--A 165 ft- t g4 ft. 2 '
Certification &)ft 261 ft g
NC well Contractor Cetcation Number • ..
( 15:OU=-aASING.(f&multi= 'ells ca L-IIQEI.t(d'_ licable v `.:..:'
Morgan Well&Pump, Inc. FROM TO' D ' THIt MMS MAnWAL
Company Name +1 Q ft 6 1181 in. sd2l pvc
l' / �t Q In:`D�II�RCA.SINGORTIIBING. •eotliermal•clo'sed-too`: "''•'•' =••' %
2.Well Construction Permit#:_.�Z^Q�"' IV v rV� `I FROM TO DIAME= THICKNESS '.�.MATERIAL
Lisa all applicable well construction permits(La UIC,Cotatty,Stale,Ym•iance,etc) L ft. i -
3.Well Use(check well use): ft. & in.
Water Supply well: FROM TO D U, SLOT SIZE TFirCKNESS TMATERLIL.'
Agricultural CiMunicipal/Public ft M in.
Geothermal(Heating/Cooling Supply) 5Kidential Water Supply(single) ft ft in•'
rndustn Commercial i Residential Water Supply(shared) ;;18:GROUT-.-. ....:..:-
Iffi tlOn FROM TO MATERIAL - F�LACEMENT METROD&AMOUNT
Non-VTater Supply Well: o fL 20 fL bentDn1 .
'Monitoring Recovery ft ft
Injection Well: ft it
Aquifer Recharge Groundwater Remediation
,.19:SAND/GRAVEL•FA:.
'Aquifer Storage and Recovery DSalinity Barrier FROM TO - MATERIAL EMPLACEMENTiYfETHOD
Aquifer Test Q1StormwaterDrainage ft ft
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) Tracer :20.tiRILLIIIG.L'OG(attaeh=additional sheefs.if fief e s_
Geothermal eating Coolie Return _I Other FROM TO DESCRIPTION(color,hardness,sail/racktype, in • etc)
(H �/ g ) (explain under#21 Remarks) � D ft.
q 0
4.Date Well(s)Completed: 6��7�L well M# ft !p ft• r ^ " G
5a.Well Location: ft Zo R VLY t
Tee,Awe, C rAw+;A ft ft
Facility/Owner Name Facility M#(if applicable) ft ft
Sjoq
Physical Address,City,,and Zip ft ft
1./�V� I f Q✓V =216R77MARTIR` _ _ _ `-i� "_ - - - - .:-�:
County -Parcel Identification No.(PIN) .'e1�f llfl:i
5b.Latitude and long tude in deb ees/minutes/seconds or decimal degrees:
Cif well field,one lat/long is sufficient)
22.C do
6.Is(are)the wells) Permanent or ©I ITempo;1o
Signatun:of C ell Contractor Date
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: Yes or with 15.4 NCAC 02C.0100 or 1SA NCAC 02C.0200 FYell Construction Standmds and that a
Ifthis is a repair•,fH out known well construction information and explain the nature of the copy ofthii record has been provided to the well 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-I is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 326 (ft-) 24a. For All Wells: Submit this form within 30 dayS of completion of well
For multiple wells list al/depths y&erent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing:_ Y� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casvzg;use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
I✓`
above, also submit one copy of this fpml within 30 days of completion of well
12.well construction method:
construction to the following:
(Le_auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FQR WATER SUPPLY V' TL LS,ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) lb Method of test: air pressure 24c.For Water SuDuiv&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: C+161'i14t, Amount: «eL completion of well construction to they county health department of the county
where constructed.
Form Gw-1 North Carolina Department of Environmental Quality-Division of water Resources I Revised 222 2016
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