GW1-2022-10230_Well Construction - GW1_20221111

1.WgWontractor -mation: I
14:.WATER ZONES<'. -
Well Co for ame IFROM TO I DESCPJPnON
ft ft
I
ft :M �.
NC Well Contractor Certification Number
� '15:OUTER.-CASIl`IG.(foi'mnlfi=easedwills)OML•II�lE,R if'a'licahla)'..:�::':;: •.`.:
Morgan Well&Pump,Inc. FROM TO I DIAlM= THICIfiYF.SS naeTm�rar.
Company Name +1 ft ft 61/8/ m' sd,21 pvc
/� 16 ROM CABINt.OR•TIIBDi?G: 'eotfiermal clo'sbd Ioo' ?.:':.;
2.WeIZ Construetion Permit Yk ZAci1 FROM TO DIAMETER TMCENMS ASATExIAL'
List all applicable well construction permits'CLe,EUC,Co'ia g gtale,Variance,etcr
3.Well Use(check well use):
ft ft in.
Water Supply Well: 17:SCREEN',: -_ .`�� •. _ :4� �,,::.;:- ?. -�:;.:. .::
FROM TO DIAMETER I SLOT SIZE THICKNESS MATMM.
Agricultural DMunicipa/Public ft ft in.
5 Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft fz
1 IndustijaVCommercial J Residential Water Supply(shared) ;�8:GROUT::,.
•.Itri ation FROM TO MATERIAL - EIS kcRuyNTmmTHOD&;OUNT
Non-Water Supply Well: o ft 20 ft bentonite. poured
t Monitoring Recovery ft. ft
Injection.WeIl:
ft ft
Aquifer Recharge Groundwater Remediaiior, ' •.
;.79:SgND/GRAYEL'P9 Cg rf a'licabre _.:::':.::_''::'. ..'•'=.'-'.'•Aquifer Storage and Recc every DSalinityBarrier FROM TO MATERIAL
—i Aquifer Test 138tormwater Drainage ft. t.
I Experimental Technology DISubsidence Control ft. ft lip{ a:+J7 t tr
Geothermal(Closed Loop) OTracer :20.DRTLG�TGDOG'(attacliliaddifiorialsheedifaeces's '••= r.:
FROM TO DESCRIPTION(color,bareness,soillrock type,grab sire,et,-
.. Geothermal(Heating/Coolmg Retum) -i Other(explain under#21 Remarks) RO It Is
ft
4.Date Well(s)Completed: , I122, Well ID# ft. So
52.Well Location: ft R �L
f Y WyQ *e� �� ft ft
Facility/Owner Nam Facility ID#(if applicable) R ftft ft.
'
�3������►�h.E��spr, �ct�ersy�lls-t,C
Physical Address,City,and Zip 7XIe ft ft.
�` � OIq�Z�3-t�lO ��D
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cif Well field,one lat/long is sufficient) a;��
'N �1- t W U
12-2
6.Is(are)the well(s) Permanent or ©•'ITemporary Signa ehfrzrtif3ed Well Contractor Date
B gning is form,I hereby cer7zfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing welh ©Tres or *No wulr 15A C 02C.0100 or ISANCAC 01C,0200 Mell Construction S2andmds and that a
Afr d1 r is a repair full out known weft construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram OY additional well details:
8.For Geoprob'e/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: SUBMTTTAL INSTRUCTIONS
9.Total well depth below Iand surface:- 2ZO (ft)
For multple*wells list all depths ifdif fereni(exmnple-3(a 200'and 2@100) a For All Wells: Submit this form within 30 days of completion of well
( construction to the following.
10.Static water level below top of casing: `'td A) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 24b.For Iniection'Wells: In addition to sending the form to the address in 24a
12.Well construction method: O (r` above, also submit one copy of this fomm within 30 days of completion of well
(Le_auger,rotary,cable,directpush,etc.) construction to the following: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,RaIeigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suunly&Iniection Wells: In addition to sending the form to
Q' the address(es) 'above, also submit one 'copy of this form within 30 days of
13b.Disinfection typ Amount• zo, completion of well construction to the county health department of the county
where constructed. I
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources' Revised 2 22 2016