GW1-2022-08507_Well Construction - GW1_20220907

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.... ��.�. I t"syr-I rorinmrnal use unly.
1.Well Contractor Information:
a� ^� J 14:. ATER ZOISES
Well Contracto Name FROM I TO DESCRIPTION r
ft ft
ft ft I ,
NC Well Contractor Certification Number
I5:OIITER:�9SING,(focmulfj raseawens)OR it"a'livable';
Morgan Well&Pump, Inc. FROM I TO' DIAMETER Tmcl wss MATERIAL
Company Name +1 H 0 ft 61181 `' sdr21 pvc
7 J� VYI�)f 16`ZiNER CeLS NG OR•TIIsMG. 'eothekifisa cl6'sid_4od"!.'::."-'._' : ' .._'.
2.Well Construction Permit#:_ t �11 FROM TO DTaMETZR THICKNESS MATERAL
List all hcable weg construction ermiis L e ft ft m
app' p UIC,Cotottv,State,Variance,etc.)•
3.Well Use(check well use): ft.
ft in.
Water Supply Well: 1�SCREEI�T',r:. : - _•: - ::.• r :'::.:-. .' : :,
FROM TO DIAMETER SLAT SIZE ,:TATCKMs MATERIAL ,.,
Agricultural CiMuaicipaUPublic ft ft tr•
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industri ommercial I Residential Water Supply(shared) GROUT..",• .. -
i ltri on FROM TO MATERIAL - EMTJ A.CEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft ben'nite poured
Monitoring DRecovery ft ft
Injection Well:
-}
Aquifer Recharge KK3 Groundwater Remediation ft fti
Aquifer Storage and Recovery Salinity Barrier FROM/PTO L PACK e MATERIAL LI 'EMPLACEMENT iIV=01)'n
_i Aquifer Test DStormwater Drainage ft ft
I Experimental Technology ©Ij•Subsidence Control ft ft
Geothermal(Closed Loop) DTracer :20.TDRILLII7GS OG'(attacti'sdditioiisl sheets if aecess -j'' %'= t
Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM TO. DESCRIPTION(color, •ardness so[Urock type n f etr
c D .ft- 7 ft ;
4.Date Well 8-Z�1_ZZ s)Completed: Well ID#f ft C Q ft
Sa.Well Location:
M ft
WA[d �►—fit C(A f
:x
Facility/Owner Name Facility ID#?(ifapplicable) ft ft
-21 l 5_toy e l'1 2� ft ft
Physical{Ad�drm,City,and Zip ft ft
��\J./VVr� �.I Q U •2Ic'R' dRKR'- - -:i" :K:"yam; L-
County Parcel IdentificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sufficient) 22.Certification:
-N o.�S C 17 W CJ `2S
6.Is(are)the well(s)aPermanent or DTemporary Sigo6rt ofC ell Contractor Date
By signing this form,I hetebv,certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well. 0 Yes or I No with 1SA NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction&andn-ds and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis 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-1 is needed. Indicate TOTAL NUMBER•of wells construction details. You may also attach additional pages ifnecessary.
dulled. / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 01D (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
Formultzple-wells list all depths ifdifferent(exampre-3@200'and 2Q100) construction to the following.
10.Static water level below top of casing: J (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino zrse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) f 24b.For Iniection Wells': In additionito sending the form to the address in 24a
12.Well construction method: L1 above, also submit one copy of this form within 30 days of completion of well
(z.e.auger,rotary,cable,dzrectpush,etc.) construction to the following: -
FOR WATER SUPPLY WELLS�ONLY Division of Water Resources,Underground Injection Control Program,
r 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm) I1 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 foam within 30 days of
13b.Disinfection type: �a ry 1 i° Amount: O completion of well construction to the jcounty health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources I Revised 222 2016