GW1-2022-10729_Well Construction - GW1_20221208

1.Well Contractor Information: 14 WArrR
FROM
• .•..DESCRIPTION ".Y
Chris Morgan !� ft. �N ft.
Well Contractor Name ft
ft.
3572-A M 4TERIAL
ING-fur-:urulti�ased.:wells 'ORZR tf a" hcable .v
QUTER CAS ( DETER THICKNESS
NC Well Contractor Certification Number FROM TO
n ft .�. in
Morgan Well & PUMP, IN
16 1IER.CA e
SING oR:TUBING' othe_imal'clused loo MATERIAL
TO DIAMETER THICKNESS
Company Name 2 / FROM in.
Lw� ft. ft.
2.Well Construction Permit#: ��e UIC,County,State,Variance,erc) ft in.
List all applicable well construction permits(' f[. _
7SCREEN �_ , SLOT SIZE THICKNESS`T:-. MATERIAL
3.Well Use(check well use): FROM TO DIAMETER
Water Supply Well: p=;{ in.
1 ' 'pal/Public
i Agricultural ft t 'n
Cooling Supply) esidential Water Supply(single)
Geothermal(Heating 1 shared EMPLACEMENT METHOD&A1vI0UNT
Residential Water Supp y( ) 1F o ROUT To ' MATERL,y
Industria]/Commercial D oared
0 ft. 20 ft. bentonite p
Ini ation
Non-Water Supply Well: ft. ft.
Recovery
1 Monitoring ft. ft.
Injection Well: pp,( c tfa`licable
Groundwater Remediation 19.;SAND/GRAAVEL MATERIAL EMPLACEMENT METHOD
Aquifer Recharge Barrier FROM TO
` I ;Salinity ft. ft.
Aquifer Storage and Recovery M Stormwater Drainage
_3 Aquifer Test
[_!Subsidence Control
_]Experimental Technology attach addifior al'sheets if necess ram size,etc) '
°20.'DRIISLIN'^TTOC'(' - DESCRIPTION(color,Lardness,sml/rock .:.�
OTracer FROM TO /�
i Geothermal(Closed Loop) O ft.
Other(explain under#21 Remarks) 0 ft. (�
Geothermal(Heating/Cooling Return) ft Oiti�
ft.
11� : / p ft. g5 ft
4.Date Well(s)Completed:1��='f— Well ID# v 1
ft. ft
Sa.Vell Location:
I`U 111111 Fa—c ft.
ility ID#(if applicable) _.-
ft. ft.
Facility/Owner N e
Physical Address,City,and Zip
' lr;
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one Iat/long is sufficient) 02
�� W
3�6a�'l N I Date
Signature of Certified Well Contractor were constructed in accordance
oTem orary I hereb cert that the wells)was( )
6.Is(are)the wells)IX'Permanent or P with
signing This form, Y
with ISANCAC 0rm,I herb ISANCAC she ells Well Constntction Stm�dards and that a
7.Is this a repair to an existing _J well: Yes or J No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the 23 Site diagram or additional' ell details
additional You may use the back of this page to provide addit well site details or well
_ repair under 421 remarks section or on the back of this form.
i construction details. You may also attach additional pages if necessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells NUMBER ofwells e
construction,only 1 GW-1 is needed. Indicate TOTAL NUM SUBMITTAL INSTRUCTIONS
drilled:' $J
(ft.) 24a. For A�ells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: le 3 00'and 1 0� construction to the following:
For multiple wells list all depths if different(exa tp
(ft.) Division
1617 Mail Seivater:Rrce CenteriRaleigh,NC 27699-1617 nit,
10.Static water level below top of casing: the form to the address in 24a
if water level is above casing,use"+"
6 1/8 (in.) 24b.For Ini_ eclls' IIn addition to sending
11.Borehole diameter: above, also submit one copy of this form within 30 days of completion of well
rotary construction
12.Well construction method: to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection, C 2769901636 Program,
1636 Mail Service Center,Raleigh,
FOR WATER SUPPLY WELLS ONLY: �;r of this form within 30 days of
24c.For Water Su l 8 Injection Wells: In addition to sending the form to
Method of test: the addresses) above, also submit one copy health department of the count)
13a.Yield(gpm) .j off— completion of well construction to the county
chlorine Amount:
13b.Disinfection type: where constructed.
f
Revised 2-22-201'
I Quality-Division of Water Resources
North Carolina Department of Environmental
F Form GWA
l