GW1-2022-10727_Well Construction - GW1_20221208

Well Con^ for ame� ft ft
/-f J CASING,(for m"niti-cised vr'ILs)02I+ .'`�'rf'a'iicable'-1:-.::•.• '
T'HZCI SS MATERIAL
cationNtmzber 15:OO R 'TO, D TFR
NC Well Contractor Cefi�i l °M in- sd21 pvc
Morgan Well&pump,Inc. +1
16:'II`IIIER
TO
,091-BIN R esmal sC sS 'r:;"M!'T L
Company Name -- — FROM ft TO in.
2.Wen construction re r1IC,Comgv,State,Yartance,etc) M.
ft•
List all applicable well construction permits( _ r ;•t:; %; i t ::
1'i•.SCREEN,r:• : -' DIAMETER SLOT ST23 1 TEr[CI� S MATERIAL.
3.WeIl Use(check well use)' FROM TO
ft mil
Water Supply Well: ft. —
DMunicipa]/Public ft
Agricultural
en Cooling Supply) pRestdenttal Water Supply(single) ,__.,.., - -- -; I�THoli&9MOUNT
Geothermal(H F/ -
b !Residential Water Supply(shared) .,:18;GRouT-:To -: ,MATERTI� cFa�i1T
1lndus Commercial — FROM ft 20 ft bentonite• poured
I7si ation 0
Non-Water Supply WeII: ft ft.
Recovery _ ft. '
Monitoring. ft
�Snjection-WeLI 79:SgNDlGRAVEL'PACK ffa"licable '= tyr;ylLM n'
i Aquifer Recharge K3 Groundwater Remedration MATF�tThL
-' Salinity Barrier FROM I- � ft•
Aquifer Storage and Recdk/ery 0 Stormwater Drainage "<
Aquifer Test
Subsidence Control vrnin s ze eta) r
1aperimentalTechnOlOgy :20.7)RILL7NTOOG(altacltDESC pTIONe(wlo hardness,SoiVrorkhP4
j3Tracer FROM `
Geothermal(closed Loop) 1 Remarks) ft.
Cooling Return) J Other(explain under#2 b ft
Geothermal(Heating/ 35 ft
,~�I Well ID# d��� ft
4.Date Well(s)Completed: ft' DlJ
ft ft.
52.Well Location:
ft ft .
Fa ility ID#(if applicable)
Facility/Owner Name 1 A,♦ ft ft c y,
Zoe V ft ft t _ :•°
Physical Address,
City,and Zip 2^'mot °2I:REMAR r ~F
parcel Identificati=NO-(PET) t
County n„-,;mtI'V2 . l:c;�•y .� tar::;
�ees/minutes/seconds or decimal degrees: 2 er rAtion:
Sb.Latitude and longitude in de n'
(if well field,oonneelattlong is sufficient)
3� �w{7 \ (7 • ���o� w Date
-N
Siena c { rtified Well Contractor (Were)constructed in accordance
y�ernanent or Q1Temporary, 13 erring ,is form,I hereby certify that the we11(s)was( ) ds and that a
6•Is(are)e)the well(s) 1 xuh ISA C 02C.0100 or 15A NCAC 02C•0200 We➢Construction Stands'
v well• ayes or 4N° copy of this record has been provided to the well owner.
7.Is this a repair to an existing lain the nature of the
If ibis is a repan',f:➢out known we➢ransiruction information and explain am Or additional,well details:
23.Site Mgr gee to provide
additional well site details or well
repair under 1121 remarks section or on the back of this farm you may use the back of this p o P saes if necessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal
Wells having
R'othe
fW511s same
construction details, you may also attach additional p
construction,only 1 OW-1 is needed. indicate TOTAL NUMB 5� l -AL INSTRUCTIONS lecon of well
drilled: Submit this form within 30 days of comp
l� (ft-) 24a. For Al_1 WO=s
9.Total well depth below land surface: le 3 00'mdd 1(a3100� construction to the following Information Processing Unit,
For multiple wells fist all depths ifdi�erent(example- (a�
.�� (ft-) Division of Water Resources, NC 27699-1617
1617 mail Service Center,Raleigh, to the address in 24a
10.Static water level below top°f casing' the��
If water level is above casing,use"+" addition to sending s of completion of well
(�) 24b.ForFar Ini�ctiOII WWells bf this form within 30 day
11.Borehole diameter: 6 above,also submit one copy
O y(� construction to the following:i ection Control Program,
~ 12.Well construction method: onnd Inj
(ie.auger,rotary,cable,direct push etc) Division of Water Resources,Un t ergr gh NC 2769 9-1 63 6
1636 Mail Service Center,Raleib the form to
FOR WATER SUPPLY WELLS ONLY: &In'ection Wells• In addition to sending
air pressure 24c.For Water Su 1 also 'submit one copy of this form within 30 days of
]Method of test: the addresses) 'above department of the county
13a.yield(gpm) bZ completion of well construction to the county health departm
Amount: where constructed
13b.Disinfection typ Revised 2 22 2016
of Enviro
North Carolina Department nmental Quality-Division of Water Resources
Form GW-1
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