GW1-2022-10724_Well Construction - GW1_20221208

0
1.Well Contractor Information:
Chris Morgan 14:WATER ZONES.
FROM TO DESCRIPTION
�� ft. ft.
Well Contractor Name 99 I'
3572-A
NC Well Contractor Certification Number 15:OUTER CASING foi multi-cased wells AR.LINER if a"` Gcable" .
Morgan Well & Pump, INC FROM ft. TO DIAhETER TffiCKNESS MATERIAI.
I it. i in.
Company Name ���� 36..I1VNER CASING OR.-TUBINGAM feothermal HICK ES
oo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. iin.
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.)
fL ft. in.
3.Well Use(check well use):
1T.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
Agricultural
Municipal/Public ft. ft. in.
in.
i Geothermal(Heating/Cooling _'Supply) esidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) '48.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
hrigation 0 ft. 20 ft* bentonile poured
Non-Water Supply Well:
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation -19.,SAND/GRA. PACK(if a "7icable
Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�, Aquifer Storage and Recovery �Salinity ft, ft.
Aquifer Test oStonnwater Drainage
Subsidence Control
:—]Experimental Technology
Geothermal(Closed Loop) OTracer 20-FROMDRILLINGT LOG attach additional sheets if.necess ")
FROM TO DESCRIPTTON(color,hardness,soil/rock ty e, rain size,etc.
Geothermal(Heating/Cooling Return) n.Other(explain under#21 Remarks) O ft. O
4.Date Well(s)Completed: t1-6 � Well ID# I ft• 5g tt. �r
5 ft. �/) ft. YM
n
Sa.Well Location: !�v
i41Q5 �ab�e. ft. ft.
Faility/Oylner Name I,II Facility/IDS#(if applicable) 'N
�QUf/lG d 1l S i �+
'. .4 .,
Phy' al Address,City,and Zip 21. M RFARKS
OuJG�VI S16 QSz a 8
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In�"+ '✓,how-=,,ivc
(if well field,one lat/long is sufficient) JCeatio35.3335 N r90 L1542 Wf Certified e Contractor Date
6.Is(are)the well(s) Permanent or Temporary constructed in accordance
By signing this form,1 hereby certify that the well waswere( )s)
7.Is this a repair to an existing well: Yes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the
copy of this record has been provided to the well owner.
repair under#t21 remarks section or on the back of this form. 23.Site diagram or additional,well details:
You may use the back of this page to provide additional well site details or well
8.For Geo only
I G or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,,o onnly W-I is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2zb (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: '
10.Static water level below top of casing: ` 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: In'addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
rotary
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servif a Center,Raleigh,NC 27699-1636
Ai r d of test: 24c.For Water Supply &Injection Wells: In addition to sending the form to
13a.Yield(gpm) MethoQ the address(es) above, also submit one copy of this form within 30 days of
chlorine Amount O� completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources