GW1-2022-08590_Well Construction - GW1_20220503

rormzernai useunly:
1.Well Contractor Information: 4
I1(C�'T�1 14:.WATII2ZONES
Well Contractor Name FROM TO .DESCRIPTION
UC5 ft \ `G IL
N b r ft ft
NC Well Contractor Certification Number
'15r OlTM:QASING:,(fo"r multi=raged zi ells)0 2 LIlyER if a'licahle'
Morgan Well&Pump, Inc. FROM TO- DIAMETER i THIt T ecI MATERIAL
Company Name A +1 ft I Co L( ft 6 1/a/ rnl. sd21 pvc
S Z 16.UlaM CASING OIt•TIIBII�G."eritfiermal r losed-rod' .. ; %
2.Well Construction Permit#: FROM TO. DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits'(Le r1IC,Cowitv,State,Yar•fance,etc)• ft ft.3.Well Use(check well use): ft 8 in.
JAgriculfural
er Supply Well: 17.�SCREEN',
FROM TO DIAMETER SLOT SIZE .^—cKNEss MATERIAL
i Municipal/Public fL ft in.othermal(Heating/Cooling Supply) Residential Water Supply(single) ft- ftustrial/Commercial DResidential Water Supply(shared) -18-GRODT._ .. .. ,-.,.� -
!Isi ation FROM TO MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring Recovery ft M
Injection Well:
ft ft
Aquifer Recharge 0I Groundwater Remediation
19:SAPID/GRAVELTACK if ii "il6bl8
Aquifer Storage and Recovery OSalinity Basier FROM To MATERML .. I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fc ft
I'Geothermal
Experimental Technology Subsidence Control ft ft
Geothermal(ClosedLoop) Tracer :20ti(Heating/Cooling Return) J3 Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color hardness,soil/rock type {grain size,etc.)
t` C)fr d ft ,r
4.Date Well(s)Completed: 4-u-n Well ID# O ft J ft. (0 w1^ t1`
Sa.Well Location: ft ft rid Sg -0-
9 a41 Q. RA / fL ft 1,
F acili�/ownerName FacilityID#(ifap!pyli�cable) ft
1
ft. ft
Pliysicdress,City,and Zip ft ft -
21:12DMARKS'-:r.: .,: ''.• ':. :'" :��<<.:.•
County ParcelIdentiScationNo.(PIM MAY ® 2029
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if welWeldlne I o`ng is sufficient) Q' Q 22.Certifica' n:
' U "N Ob,—I 7 •�� f is
W P�•( Z6 2�2t.
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor !Date
i
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OXes or &to with 15A NCAC 01C.0100 or 15A NCAC 01C:'0100 Well Construction Standards and that a
Ifthis is a repair frll out known weII construction information and erplain the nature ofthe copy ofrhis record has beers provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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.
drilled: * - I ' (�/ 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 all depths ifdiei•ent(example-3(_200'pn¢1Q100D construction to the following.
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
I1.Borehole diameter: 6 (in.) 24b.For Iniection W' eIls': In addition to'sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLX• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5_6 Method of test- air pressure 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
� the address(es) 'above, also submit one copy of this form within 30 days of
(S 13b.Disinfection type:� WV)01 L Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2 22-2016